Nokea
A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data?
- A. Postural hypotension
- B. Urinary output of 10 mL/hr
- C. Altered consciousness
- D. Extreme pallor
Correct Answer: A
Rationale: Symptoms of chronic hypovolemic anemia include pallor, fatigue, chills, postural hypotension, and rapid heart rate and respiratory rates. The symptom of decreased urinary output, altered consciousness, and extreme pallor are all signs of acute hypovolemic anemia from severe blood loss. These signs indicate hypovolemic shock.
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The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit?
- A. Excessive consumption of coffee or tea
- B. Elimination of iron by the body
- C. Decrease in the total body iron stores with age
- D. Blood loss from the gastrointestinal or genitourinary tract
Correct Answer: D
Rationale: If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron-deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.
Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the correct response by the nurse?
- A. Most likely, the father is the carrier of the gene.
- B. The trait is passed down through the mother.
- C. The child must inherit two defective genes, one from each parent.
- D. It is an acquired, not a hereditary disorder.
Correct Answer: C
Rationale: Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, that person carries the sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other options are incorrect due to these factors.
The +2:21client was admitted to the Emergency Department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the nurse assess for?
- A. Malabsorption disorders
- B. Postural hypotension
- C. Fatigue
- D. Reduced urine output
Correct Answer: D
Rationale: Acute hypovolemic anemia from severe blood loss is evidenced by the signs and symptoms of hypovolemic shock, which include reduced urine output. The symptoms of chronic hypovolemic anemia include fatigue and postural hypotension. Clients with malabsorption disorders are at great risk of iron deficiency anemia.
A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
- A. Administer blood.
- B. Notify the physician.
- C. Insert two large-bore intravenous catheters.
- D. Administer a colloid solution.
Correct Answer: B
Rationale: A systolic blood pressure below 90 mm Hg and heart rate above 100 beats/minute should be reported immediately. Administering blood, inserting two large-bore IV catheters, and administration of a colloid solution should be performed only with a physician's prescription and may not be required at this time.
A client diagnosed with polycythemia vera has come into the clinic because they have developed a night-time cough, fatigue, and shortness of breath. From these clinical manifestations, what complication would the nurse suspect in this client?
- A. Stroke
- B. Tissue infarction
- C. Congestive heart failure
- D. Pulmonary embolus
Correct Answer: C
Rationale: The symptoms exhibited by this client are indicative of heart failure. Complications of polycythemia vera include hypertension, heart failure, stroke, tissue and organ infarction, and hemorrhage.