Nokea
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.
You may also like to solve these questions
The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?
- A. I feel hot all of the time.
- B. I have a difficult time falling asleep at night.
- C. I have an increase in my appetite.
Correct Answer: D
Rationale: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.
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 with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client?
- A. Vaso-occlusive crisis
- B. Pneumocystis pneumonia
- C. Acute chest syndrome
- D. Acute muscular strain
Correct Answer: C
Rationale: One of the unique manifestations of sickle cell disease is 'acute chest syndrome,' a type of pneumonia triggered by decreased hemoglobin and infiltrates in the lungs. Acute chest syndrome is characterized by respiratory symptoms, such as coughing, wheezing, tachypnea, and chest pain. Vaso-occlusive crisis causes decrease in tissue perfusion and predisposes the client to pneumonia but is not the present problem with this client. Pneumocystis pneumonia is present in the client with HIV/AIDS or other immunocompromised clients. The client's symptoms do not correlate with a diagnosis of acute muscular strain.
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?
- A. Notify the charge nurse.
- B. Prepare to assist with intubation.
- C. Give oxygen per nasal cannula
- D. Place the client in the supine position.
Correct Answer: C
Rationale: An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.
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.