Nokea
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.
- A. Infection
- B. Blood loss
- C. Abnormal erythrocyte production
- D. Destruction of normally formed red blood cells
- E. Inadequate formed white blood cells
Correct Answer: B,C,D
Rationale: Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.
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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.
A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?
- A. The client has a decreased tolerance of pain related to the chronic nature of the illness.
- B. Bone marrow decreases the erythrocyte production causing decrease in hypoxia.
- C. Overhydration enlarges the red blood cells.
- D. Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.
Correct Answer: D
Rationale: The person with sickle cell disease repeatedly suffers from two major problems: (1) episodes of sickle cell crisis from vascular occlusion, which develops rapidly under hypoxic conditions, and (2) chronic hemolytic anemia. During a sickle cell crisis, the sickle-shaped cells lodge in small blood vessels, where they block the flow of blood and oxygen to the affected tissue. The vascular occlusion induces severe pain in the ischemic tissue. The client may have increased tolerance for pain due to the chronic nature of the illness. Bone marrow increases the erythrocyte production. Underhydration increases the client's risk of developing a vaso-occlusive crisis.
The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which client(s) would receive the greatest benefit from this program? Select all that apply.
- A. An adolescent client with bulimia nervosa
- B. An older adult client on a fixed income
- C. A client with Crohn's disease
- D. A client who lives in a nursing home
- E. A client who is a vegetarian
Correct Answer: A,B,C
Rationale: Those who consume a healthy diet absorb less than 10% of the iron in food. Clients whose nutrition is compromised by unhealthy dieting or who cannot afford to eat a healthy diet, lack knowledge about nutrition, or have malabsorption disorders are at great risk for iron-deficiency anemia. An adolescent client with bulimia nervosa has an unhealthy diet. An older adult client on a fixed income may not have the funds to eat a healthy diet. A client with Crohn's disease has a malabsorption syndrome. A client who resides in a nursing home has prepared meals as well as available supplements if required. A client who is a vegetarian is still able to receive ample iron supplementation in the vegetables being eaten.
A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate?
- A. Loss of vibratory and position senses
- B. Neurologic involvement
- C. Severity of the disease
- D. Insufficient intake of dietary nutrients
Correct Answer: B
Rationale: In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms.
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.