Chapter 28: Assessment of Hematologic Function and Treatment Modalities
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate?
A. Stool for occult blood
B. Bone marrow biopsy
C. Lumbar puncture
D. Urinalysis
ANS: A
Rationale: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant.
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 nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it?
A. Inflammation of the lining of the stomach
B. Erosion of the lining of the stomach or intestine
C. Bleeding from the mucosa in the stomach
D. Viral invasion of the stomach wall
ANS: B
Rationale: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics.
A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
A. Insertion of a nasogastric tube
B. Insertion of a central venous catheter
C. Administration of a mineral oil enema
D. Administration of a glycerin suppository and an oral laxative
ANS: A
Rationale: Decompression of the bowel through a nasogastric tube is necessary for all clients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.
The advanced practice nurse is attempting to examine the client's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the client's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
A. Maintain the irrigation fluid at a warm temperature.
B. Instill short, sharp bursts of fluid into the ear canal.
C. Follow the procedure with insertion of a cerumen curette to extract missed ear wax.
D. Have the client stand during the procedure.
ANS: A
Rationale: Warm water (never cold or hot) and gentle, not forceful, irrigation should be used to remove cerumen. Too forceful irrigation can cause perforation of the tympanic membrane, and ice water causes vomiting. Cerumen curettes should not be routinely used by the nurse. Special training is required to use a curette safely. It is unnecessary to have the client stand during the procedure.
The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take?
A. Notify the client's health care provider.
B. Stop the transfusion immediately.
C. Remove the client's IV access.
D. Assess the client's chest sounds and vital signs.
ANS: B
Rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed.
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 nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that the client was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis?
A. Gastric cancer does not cause signs or symptoms until metastasis has occurred.
B. Adherence to screening recommendations for gastric cancer is exceptionally low.
C. Early symptoms of gastric cancer are usually attributed to constipation.
D. The early symptoms of gastric cancer are usually not alarming or highly unusual.
ANS: D
Rationale: Symptoms of early gastric cancer, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive. Symptoms are rarely a cause for alarm or for detailed diagnostic testing. Symptoms precede metastasis, however, and do not include constipation.
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
A. Administer a Fleet enema as prescribed and remain with the client.
B. Contact the primary care provider promptly and report these signs of perforation.
C. Position the client supine and insert an NG tube.
D. Page the primary provider and report that the client may be obstructed.
ANS: B
Rationale: The client's change in status is suggestive of perforation, which is a surgical emergency. Obstruction does not have this presentation involving fever and abdominal rigidity. An enema would be strongly contraindicated. An order is needed for NG insertion and repositioning is not a priority.
The nurse in the ED is caring for a child brought in by the parents who state that the child will not stop crying and pulling at the child’s ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis?
A. External otitis is characterized by aural tenderness.
B. External otitis is usually accompanied by a high fever.
C. External otitis is usually related to an upper respiratory infection.
D. External otitis can be prevented by using cotton-tipped applicators to clean the ear.
ANS: A
Rationale: Clients with otitis externa usually exhibit pain, discharge from the external auditory canal, and aural tenderness. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external otitis so their use should be avoided.
The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)?
A. Production of inadequate quantities of RBCs
B. Premature release of immature RBCs
C. Injury to the RBCs in circulation
D. Abnormalities in the structure and function of RBCs
ANS: D
Rationale: Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs.
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 nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem?
A. Consumes one or more protein drinks daily.
B. Takes over-the-counter antacids frequently throughout the day.
C. Smokes one pack of cigarettes daily.
D. Reports a history of social drinking on a weekly basis
ANS: C
Rationale: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in clients with a history of consumption of alcohol on a daily basis.
The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action?
A. Contact the care provider to have the client's hemoglobin and hematocrit measured.
B. Document these expected assessment findings.
C. Apply barrier ointment to the stoma as prescribed.
D. Cleanse the stoma with alcohol or chlorhexidine.
ANS: B
Rationale: Redness and slight bleeding are expected, so no further intervention or assessment is likely necessary.
Following a motorcycle accident, an adolescent client is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
A. The malleus can be visualized during otoscopic examination.
B. The tympanic membrane is pearly gray.
C. Tenderness is reported by the client when the mastoid area is palpated.
D. Clear, watery fluid is draining from the client's ear.
ANS: D
Rationale: For the client experiencing acute head trauma, immediately report the presence of clear, watery drainage from the ear. The fluid is likely to be cerebrospinal fluid associated with skull fracture. The ability to visualize the malleus is a normal physical assessment finding. The tympanic membrane is normally pearly gray in color. Tenderness of the mastoid area usually indicates inflammation. This should be reported, but is not a finding indicating urgent intervention.
A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance?
A. Vitamin E
B. Vitamin D
C. Iron
D. Magnesium
ANS: C
Rationale: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased.
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 community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include?
A. Enteral feeding via gastrostomy tube (G tube)
B. Gastrointestinal decompression by nasogastric tube
C. Periodic assessment for esophageal distension
D. Administration of injections of vitamin B12
ANS: D
Rationale: Since vitamin B12 is absorbed in the stomach, the client requires vitamin B12 replacement to prevent pernicious anemia. A gastrectomy precludes the use of a G tube. Since the stomach is absent, a nasogastric tube would not be indicated. As well, this is not possible in the home setting. Since there is no stomach to act as a reservoir and fluids and nutrients are passing directly into the jejunum, distension is unlikely.
A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function?
A. Use glycerin suppositories on a regular basis.
B. Limit physical activity in order to promote bowel peristalsis.
C. Consume high-residue, high-fiber foods.
D. Resist the urge to defecate until the urge becomes intense.
ANS: C
Rationale: Goals for the client include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit?
A. Recent completion of radiation therapy for treatment of thyroid cancer
B. Routine use of quinine for management of leg cramps
C. Allergy to hair coloring and hair spray
D. Previous perforation of the eardrum
ANS: B
Rationale: Long-term, regular use of quinine for management of leg cramps is associated with loss of hearing acuity. Radiation therapy for cancer should not affect hearing; however, hearing can be significantly compromised by chemotherapy. Allergy to hair products may be associated with otitis externa; however, it is not linked to hearing loss. An ear drum that perforates spontaneously due to the sudden drop in altitude associated with a high dive usually heals well and is not likely to become infected. Recurrent otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the middle ear.
Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply.
A. Leukocytes
B. Natural killer cells
C. Cytokines
D. Platelets
E. Erythrocytes
ANS: A, D, E
Rationale: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and cytokines do not originate as myeloid stem cells.
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.
An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply.
A. Avoid drinking alcohol
B. Adopt a low-residue diet
C. Avoid nonsteroidal anti-inflammatories
D. Take calcium gluconate as prescribed
E. Prepare for the possibility of surgery
ANS: A, C
Rationale: Clients with chronic gastritis are encouraged to avoid alcohol and NSAIDs. Calcium gluconate is not a common treatment and the condition is not normally treated with surgery. Dietary modifications are usually recommended, but this does not necessitate a low-residue diet.
An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.
A. Anticholinergic medications
B. Increased fiber intake
C. Enemas on alternating days
D. Reduced fat intake
E. Fluid reduction
ANS: B, D
Rationale: Clients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.
The nurse is providing care for a client who has benefited from a cochlear implant. The nurse should understand that this client's health history likely includes which of the following? Select all that apply.
A. The client was diagnosed with sensorineural hearing loss.
B. The client's hearing did not improve appreciably with the use of hearing aids.
C. The client has deficits in peripheral nervous function.
D. The client's hearing deficit is likely accompanied by a cognitive deficit.
E. The client is unable to lip-read.
ANS: A, B
Rationale: A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. The need for a cochlear implant is not associated with deficits in peripheral nervous function, cognitive deficits, or an inability to lip-read.