Nokea
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.
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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.
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 is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin?
- A. Bronzing of the skin
- B. Jaundice of the skin and mucous membranes
- C. Ruddy complexion
- D. Pale skin and mucous membranes
Correct Answer: A
Rationale: Clients with Cooley's anemia, a severe form of beta-thalassemia, exhibit symptoms of severe anemia and a bronzing of the skin caused by hemolysis of erythrocytes. The client is not jaundiced, ruddy, or pale with this disorder.
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 observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?
- A. Erythrocytes that are microcytic and hypochromic
- B. Erythrocytes that are macrocytic and hyperchromic
- C. Clustering of platelets with sickled red blood cells
- D. An increased number of erythrocytes
Correct Answer: A
Rationale: A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera.