Nokea
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?
- A. Aplastic anemia
- B. Pernicious anemia
- C. Iron-deficiency anemia
- D. Agranulocytosis
Correct Answer: A
Rationale: Clients with aplastic anemia experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells. The blood cell count shows insufficient numbers of blood cells. A bone marrow aspiration confirms that the production of stem cells is suppressed. This scenario does not describe a client with pernicious anemia, iron-deficiency anemia, or agranulocytosis.
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The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?
- A. Trauma and microabrasions from a non-electric razor may contribute to anemia.
- B. Strong tissues and intact clotting mechanisms may prevent hemorrhage.
- C. The client is at risk for spontaneous and uncontrolled bleeding.
- D. The client is not at risk for infection from microorganisms.
Correct Answer: A
Rationale: In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action?
- A. Evaluate the client's dietary intake.
- B. Observe the client's stools for blood.
- C. Monitor the client's body temperature.
- D. Monitor the client's blood pressure (BP).
Correct Answer: B
Rationale: If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?
- A. Hematuria
- B. Blood pressure of 90/60 mm Hg
- C. Jaundice of the sclera
- D. Urine output of 15 mL/hour
Correct Answer: D
Rationale: Urine output of less than 30 to 50 mL/hour reflects inadequate renal perfusion. The kidneys must excrete 30 to 50 mL/hour or 500 mL/24 hours to eliminate wastes sufficiently. Hematuria is an indicator of other problems such as hemorrhagic cystitis, trauma to the bladder, etc. It is not an indicator of renal perfusion. A blood pressure of 90/60 mm Hg does not indicate that the client is having a decrease in renal perfusion nor does jaundice. Jaundice is present when the liver starts to fail.
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?
- A. Do not take medication with orange juice because it will delay absorption of the iron.
- B. Iron may cause indigestion and should be taken with an antacid such as Mylanta.
- C. Dilute the liquid preparation with another liquid such as juice and drink with a straw.
- D. Discontinue the use of iron if your stool turns black.
Correct Answer: C
Rationale: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.
The nurse reinforces education for a client who is diagnosed with a coagulopathy. Which client statement indicates a correct understanding of the definition for this disorder?
- A. My diagnosis means that I am missing or lacking components needed to control bleeding.
- B. My diagnosis is a bleeding disorder caused by a deficiency of globulins in my blood.
- C. My diagnosis is a bleeding disorder that involves red blood cells.
- D. My diagnosis means that I am at risk for developing blood clots.
Correct Answer: A
Rationale: The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate. Two common examples are thrombocytopenia and hemophilia. Coagulopathies do not involve red blood cells, nor are they characterized by a deficiency of globulins in the plasma.