Chapter 29 Flashcards
(38 cards)
A client with sickle cell disease is taking narcotic analgesics for pain control. Which
intervention by the nurse would decrease the risk for narcotic substance abuse?
A. Encourage the client to rely on complementary and alternative therapies.
B. Encourage the client to seek care from a single provider for pain relief.
C. Teach the client to accept chronic pain as an inevitable aspect of the disease.
D. Limit the reporting of emergency department visits to the primary health care
provider.
ANS: B
Rationale: The client should be encouraged to use a single primary provider to address
health care concerns. Emergency department visits should be reported to the primary
provider to achieve optimal management of the disease. It would be inappropriate to
teach the client to simply accept the pain. Complementary therapies are usually
insufficient to fully address pain in sickle cell disease.
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After
the admission assessment, the client asks the nurse to explain the condition. The nurse
explains to this client that this condition occurs due to which factor?
A. An attack on the platelets by antibodies
B. Decreased production of platelets
C. Impaired communication between platelets
D. An autoimmune process causing platelet malfunction
ANS: B
Rationale: Thrombocytopenia can result from a decreased platelet production, increased
platelet destruction, or increased consumption of platelets. Impaired platelet
communication, antibodies, and autoimmune processes are not typical pathologies.
A critical care nurse is caring for a client with immune hemolytic anemia. The client is
not responding to conservative treatments, and the client’s condition is now becoming
life-threatening. The nurse is aware that a treatment option in this case may include
which intervention?
A. Hepatectomy
B. Vitamin K administration
C. Platelet transfusion
D. Splenectomy
ANS: D
Rationale: A splenectomy may be the course of treatment if autoimmune hemolytic
anemia does not respond to conservative treatment. Vitamin K administration is
treatment for vitamin K deficiency and does not resolve anemia. Platelet transfusion may
be the course of treatment for some bleeding disorders. Hepatectomy would not help the
client.
A nurse is providing education to a client with iron deficiency anemia who has been
prescribed iron supplements. What should the nurse include in health education?
A. Take the iron with dairy products to enhance absorption.
B. Increase the intake of vitamin E to enhance absorption.
C. Iron will cause the stools to darken in color.
D. Limit foods high in fiber due to the risk for diarrhea.
ANS: C
Rationale: The nurse will inform the client that iron will cause the stools to become dark
in color. Iron should be taken on an empty stomach, as its absorption is affected by food,
especially dairy products. Clients should be instructed to increase their intake of vitamin
C to enhance iron absorption. Foods high in fiber should be consumed to minimize
problems with constipation, a common side effect associated with iron therapy.
The nurse is assessing a new client with reports of acute fatigue and a sore tongue that
is visibly smooth and beefy red. This client is demonstrating signs and symptoms
associated with what form of hematologic disorder?
A. Sickle cell disease
B. Hemophilia
C. Megaloblastic anemia
D. Thrombocytopenia
ANS: C
Rationale: A red, smooth, sore tongue is a symptom associated with megaloblastic
anemia. Sickle cell disease, hemophilia, and thrombocytopenia do not have symptoms
involving the tongue.
A client with acute kidney injury has decreased erythropoietin production. Upon
analysis of the client’s complete blood count, the nurse will expect which of the following
results?
A. An increased hemoglobin and decreased hematocrit
B. A decreased hemoglobin and hematocrit
C. A decreased mean corpuscular volume (MCV) and red cell distribution width
(RDW)
D. An increased mean corpuscular volume (MCV) and red cell distribution width
(RDW)
ANS: B
Rationale: The decreased production of erythropoietin will result in a decreased
hemoglobin and hematocrit. The client will have normal MCV and RDW because the
erythrocytes are normal in appearance.
A client comes to the clinic reporting fatigue and the health interview is suggestive of
pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what
would the nurse suspect that the client will be diagnosed?
A. Iron deficiency anemia
B. Pernicious anemia
C. Sickle cell disease
D. Hemolytic anemia
ANS: A
Rationale: A low serum iron level, a low ferritin level, and symptoms of pica are
associated with iron deficiency anemia. TIBC may also be elevated. None of the other
anemias are associated with pica.
A client comes into the clinic reporting fatigue. Blood work shows an increased bilirubin
concentration and an increased reticulocyte count. Which condition should the nurse
most suspect the client has?
A. A hypoproliferative anemia
B. A leukemia
C. Thrombocytopenia
D. A hemolytic anemia
ANS: D
Rationale: In hemolytic anemias, premature destruction of erythrocytes results in the
liberation of hemoglobin from the erythrocytes into the plasma; the released hemoglobin
is converted in large part to bilirubin, and therefore the bilirubin concentration rises. The
increased erythrocyte destruction leads to tissue hypoxia, which in turn stimulates
erythropoietin production. This increased production is reflected in an increased
reticulocyte count as the bone marrow responds to the loss of erythrocytes.
Hypoproliferative anemias, leukemia, and thrombocytopenia lack this pathology and
presentation.
A client is admitted to the hospital with pernicious anemia. The nurse should prepare
to administer which of the following medications?
A. Folic acid
B. Vitamin B12
C. Lactulose
D. Magnesium sulfate
ANS: B
Rationale: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium
sulfate, lactulose, and folic acid do not address the pathology of this type of anemia.
A client’s blood work reveals a platelet level of 17,000/mm3. When inspecting the
client’s integumentary system, what finding would be most consistent with this platelet
level?
A. Dermatitis
B. Petechiae
C. Urticaria
D. Alopecia
ANS: B
Rationale: When the platelet count drops to less than 20,000/mm3, petechiae can
appear. Low platelet levels do not normally result in dermatitis, urticaria (hives), or
alopecia (hair loss).
A nurse is admitting a client with immune thrombocytopenic purpura to the unit. In
completing the admission assessment, the nurse must be alert for what medications that
potentially alter platelet function? Select all that apply.
A. Antihypertensives
B. Penicillins
C. Sulfa-containing medications
D. Aspirin-based drugs
E. NSAIDs
ANS: C, D, E
Rationale: The nurse must be alert for sulfa-containing medications and others that alter
platelet function (e.g., aspirin-based or other NSAIDs). Antihypertensive drugs and the
penicillins do not alter platelet function.
A 25-year-old client comes to the emergency department with excessive bleeding
from a cut sustained when cleaning a knife. Blood work shows a prolonged prothrombin
time (PT), but a vitamin K deficiency is ruled out. When assessing the client, areas of
ecchymosis are noted on other areas of the body. Which of the following is the most
plausible cause of the client’s signs and symptoms?
A. Lymphoma
B. Leukemia
C. Hemophilia
D. Hepatic dysfunction
ANS: D
Rationale: Prolongation of the PT, unless it is caused by vitamin K deficiency, may
indicate severe hepatic dysfunction. Liver dysfunction can lead to decreased amount of
factors needed for coagulation and hemostasis. The majority of hemophiliacs are
diagnosed as children. The scenario does not describe signs or symptoms of lymphoma or
leukemia.
A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding
esophageal varices; an attempt to stop the bleeding has been only partially successful.
What would the critical care nurse expect the care team to prescribe for this client?
A. Packed red blood cells (PRBCs)
B. Vitamin K
C. Oral anticoagulants
D. Heparin infusion
ANS: A
Rationale: Clients with liver dysfunction may have life-threatening hemorrhage from
peptic ulcers or esophageal varices. In these cases, replacement with fresh-frozen
plasma, PRBCs, and platelets is usually required. Vitamin K may be prescribed once the
bleeding is stopped, but that is not what is needed to stop the bleeding of the varices.
Anticoagulants would exacerbate the client’s bleeding.
The nurse on the pediatric unit is caring for a 10-year-old child with a diagnosis of
hemophilia. The nurse should assess carefully for indication of what nursing diagnosis?
A. Hypothermia
B. Diarrhea
C. Ineffective coping
D. Imbalanced nutrition: Less than body requirements
ANS: C
Rationale: Most clients with hemophilia are diagnosed as children. They often require
assistance in coping with the condition because it is chronic, places restrictions on their
lives, and is an inherited disorder that can be passed to future generations. Children with
hemophilia are not at risk of hypothermia, diarrhea, or imbalanced nutrition.
A group of nurses are learning about the high incidence and prevalence of anemia
among different populations. Which individual is most likely to have anemia?
A. A 50-year-old black woman who is going through menopause
B. An 81-year-old woman who has chronic heart failure
C. A 48-year-old man who travels extensively and has a high-stress job
D. A 13-year-old girl who has just experienced menarche
ANS: B
Rationale: The incidence and prevalence of anemia are exceptionally high among older
adults, and the risk of anemia is compounded by the presence of heart disease. None
of
the other listed individuals exhibits high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia.
An adult client has been diagnosed with iron-deficiency anemia. What nursing
diagnosis is most likely to apply to this client’s health status?
A. Risk for deficient fluid volume related to impaired erythropoiesis
B. Risk for infection related to tissue hypoxia
C. Acute pain related to uncontrolled hemolysis
D. Fatigue related to decreased oxygen-carrying capacity
ANS: D
Rationale: Fatigue is the major assessment finding common to all forms of anemia.
Anemia does not normally result in acute pain or fluid deficit. The client may have an
increased risk of infection due to impaired immune function, but fatigue is more likely.
A client has been living with a diagnosis of anemia for several years and has
experienced recent declines in hemoglobin levels despite active treatment. Which
assessment finding would signal complications of anemia?
A. Venous ulcers and visual disturbances
B. Fever and signs of hyperkalemia
C. Epistaxis and gastroesophageal reflux
D. Shortness of breath and peripheral edema
ANS: D
Rationale: A significant complication of anemia is heart failure from chronic diminished
blood volume and the heart’s compensatory effort to increase cardiac output. Clients with
anemia should be assessed for signs and symptoms of heart failure, including dyspnea
and peripheral edema. None of the other listed signs and symptoms is characteristic of
heart failure.
A woman who is in her third trimester of pregnancy has been experiencing an
exacerbation of iron-deficiency anemia in recent weeks. When providing the client with
nutritional guidelines and meal suggestions, what foods would be most likely to increase
the woman’s iron stores?
A. Salmon accompanied by whole milk
B. Mixed vegetables and brown rice
C. Beef liver accompanied by orange juice
D. Yogurt, almonds, and whole grain oats
ANS: C
Rationale: Food sources high in iron include organ meats, other meats, beans (e.g., black
and pinto), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a
source of vitamin C (e.g., orange juice) enhances the absorption of iron. All of the listed
foods are nutritious, but liver and orange juice are most likely to be of benefit to iron
stores.
A nurse is planning the care of a client with a diagnosis of sickle cell disease who has
been admitted for the treatment of an acute vaso-occlusive crisis. Which nursing
diagnosis should the nurse prioritize in the client’s plan of care?
A. Risk for disuse syndrome related to ineffective peripheral circulation
B. Functional urinary incontinence related to urethral occlusion
C. Ineffective tissue perfusion related to thrombosis
D. Ineffective thermoregulation related to hypothalamic dysfunction
ANS: C
Rationale: There are multiple potential complications of sickle cell disease and sickle cell
crises. Central among these, however, is the risk of thrombosis and consequent lack of
tissue perfusion. Sickle cell crises are not normally accompanied by impaired
thermoregulation or genitourinary complications. Risk for disuse syndrome is not
associated with the effects of acute vaso-occlusive crisis.
A client is being treated on the medical unit for a sickle cell crisis. The nurse’s most
recent assessment reveals a fever and a new onset of fine crackles on lung auscultation.
Which action by the nurse would be the most appropriate?
A. Apply supplementary oxygen by nasal cannula.
B. Administer bronchodilators by nebulizer.
C. Liaise with the respiratory therapist and consider high-flow oxygen.
D. Inform the health care provider that the client may have an infection.
ANS: D
Rationale: Clients with sickle cell disease are highly susceptible to infection, thus any
early signs of infection should be reported promptly. There is no evidence of respiratory
distress, so oxygen therapy and bronchodilators are not indicated.
When teaching a client with sickle cell disease about strategies to prevent crises,
what measures should the nurse recommend?
A. Using prophylactic antibiotics and performing meticulous hygiene
B. Maximizing physical activity and taking OTC iron supplements
C. Limiting psychosocial stress and eating a high-protein diet
D. Avoiding cold temperatures and ensuring sufficient hydration
ANS: D
Rationale: Keeping warm and providing adequate hydration can be effective in
diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein
intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.
A client with a documented history of glucose-6-phosphate dehydrogenase deficiency
has presented to the emergency department with signs and symptoms including pallor,
jaundice, and malaise. Which of the nurse’s assessment questions relates most directly
to this client’s hematologic disorder?
A. “When did you last have a blood transfusion?”
B. “What medications have you taken recently?”
C. “Have you been under significant stress lately?”
D. “Have you suffered any recent injuries?”
ANS: B
Rationale: Exacerbations of glucose-6-phosphate dehydrogenase deficiency are nearly
always precipitated by medications. Blood transfusions, stress, and injury are less
common triggers.
A client’s electronic health record notes that the client has previously undergone
treatment for secondary polycythemia. The nurse should assess for which factor?
A. Recent blood donation
B. Evidence of lung disease
C. A history of venous thromboembolism
D. Impaired renal function
ANS: B
Rationale: Any reduction in oxygenation, such as lung disease, can cause secondary
polycythemia. Blood donation does not precipitate this problem and impaired renal
function typically causes anemia, not polycythemia. A history of venous
thromboembolism is not a likely contributor.
A client’s absolute neutrophil count (ANC) is 440/mm3 but the nurse’s assessment
reveals no apparent signs or symptoms of infection. What action should the nurse
prioritize when providing care for this client?
A. Meticulous hand hygiene
B. Timely administration of antibiotics
C. Provision of a nutrient-dense diet
D. Maintaining a sterile care environment
ANS: A
Rationale: Providing care for a client with neutropenia requires that the nurse adhere
closely to standard precautions and infection control procedures. Hand hygiene is central
to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a
sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central
aspect of care.
