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Hematologic Problems Examination
A 25 - year-old man who was recently diagnosed with Hodgkin's disease in the pelvic area is about to begin radiation therapy and he expresses concern about becoming infertile. What should the patient be told about sexual function? A. Impotence may occur, but it will only be temporary. B. Sperm cells will mature, resulting in deformed offspring. C. Permanent sterility can occur; thus sperm banking should be considered. D. Changes in secondary sex characteristics, including breast enlargement, may occur with chemotherapy. - answers>>Answer: C Rationale: Fertility issues may be of particular concern with the disease and the related treatment. A complication of the hyperviscosity of polycythemia is A. thrombosis. B. cardiomyopathy. C. pulmonary edema. D. disseminated intravascular coagulation (DIC). - answers>>Answer: A Rationale: Thrombosis is the most likely complication. The patient with polycythemia may experience angina, heart failure, intermittent claudication, and thrombophlebitis, which may be complicated by embolization. The most common and serious acute complication is stroke due to thrombosis. A factor unique to non-Hodgkin's lymphoma is that A. relapses are unlikely. B. treatment is limited to chemotherapy. C. more aggressive tumors respond effectively to treatment. D. tumors are present only in the lymph glands. - answers>>Answer: C Rationale: More aggressive non-Hodgkin lymphomas respond to treatment and are more likely to be cured. Treatment includes irradiation and chemotherapy. Relapses are common. Unlike Hodgkin's disease, non-Hodgkin's lymphomas occur in non-nodal sites. A patient with a diagnosis of hemophilia fell down an escalator earlier in the day and is now experiencing bleeding in her left knee joint. Your immediate response should include A. immediate transfusion of platelets. B. resting the patient's knee to prevent hemarthroses. C. assistance with intracapsular injection of corticosteroids. D. range-of-motion exercises to prevent thrombus formation. - answers>>Answer: B
Rationale: In patients with hemophilia, joint bleeding requires resting of the joint to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia. A patient with acute myelogenous leukemia will soon start chemotherapy. When you are teaching the patient about the induction stage of chemotherapy, what is the best explanation? A. The drugs are started slowly to minimize side effects. B. You will develop even greater bone marrow depression with risk for bleeding and infection. C. It will be necessary to have high-dose treatment every day for several months. D. During this time you will regain energy and become more resistant to infection. - answers>>Answer: C Rationale: The chemotherapeutic treatment of acute leukemia is often divided into stages. The first stage, induction therapy, is the attempt to induce or bring about a remission. Induction is aggressive treatment that seeks to destroy leukemic cells in the tissues, peripheral blood, and bone marrow in order to eventually restore normal hematopoiesis on bone marrow recovery. During induction therapy a patient may become critically ill because the bone marrow is severely depressed by the chemotherapeutic agents. A patient with multiple myeloma becomes confused and lethargic. You would expect that these clinical manifestations may be explained by diagnostic results that indicate A. hyperkalemia. B. hyperuricemia. C. hypercalcemia. D. CNS myeloma. - answers>>Answer: C Rationale: Bony degeneration in multiple myeloma causes calcium to be lost from bones, eventually causing hypercalcemia. Hypercalcemia may cause renal, GI, or neurologic manifestations such as polyuria, anorexia, confusion, and ultimately seizures, coma, and cardiac problems. A patient with non-Hodgkin's lymphoma asks why staging is so important. The accurate response to his question is that staging is done to A. determine if you have favorable histology. B. establish your short- and long-term prognoses. C. properly code your disease for statistical purposes. D. help identify the most effective chemotherapy protocols. - answers>>Answer: D Rationale: Clinical staging is used to help guide therapy. Because myelodysplastic syndrome (MDS) arises from the pluripotent hematopoietic stem cells in the bone marrow, expected laboratory results include
B. assist with or perform phlebotomy at the bedside. C. teach the patient how to maintain a low-activity lifestyle. D. perform thorough and regularly scheduled neurologic assessments. - answers>>Answer: B Rationale: Primary polycythemia often requires phlebotomy to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep-breathing and coughing exercises do not directly address the cause or common sequelae of polycythemia, and neurologic manifestations are not typical. Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction for red blood cells are A. chills and hemolysis. B. leukostasis and neutrophilia. C. fluid overload and pulmonary edema. D. transmission of cytomegalovirus and fever. - answers>>Answer: D Rationale: Infectious viruses, HIV, human herpesvirus agents transmitted by blood transfusion include hepatitis B and C type 6 (HSV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus, type 1 (HTLV-1), cytomegalovirus (CMV), and malaria. Leukocyte- reduced blood products drastically reduce the risk of blood transfusion-associated viral infections, including CMV. Disseminated intravascular coagulation (DIC) is a disorder in which A. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels. B. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts. C. a disease process stimulates coagulation processes with resultant thrombosis and depletion of clotting factors, leading to diffuse clotting and hemorrhage. D. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature. - answers>>Answer: C Rationale: DIC is a disease process in which there is stimulation of the coagulation process with resultant thrombosis and depletion of clotting factors, leading to diffuse clotting and hemorrhage. The paradox of this condition is characterized by the profuse bleeding that results from the depletion of platelets and clotting factors. Disseminated intravascular coagulation (DIC) is initiated by intravascular release of which substance? A. Platelets B. Fibrin C. Thrombin D. Histamine - answers>>Answer: C
Rationale: In DIC, abundant intravascular thrombin, the most powerful coagulant, is produced. This converts fibrinogen to fibrin and promotes platelet aggregation. Platelets do not initiate the response. Histamine does not play a role in DIC. If the patient with DIC is actively bleeding, platelets are given to correct thrombocytopenia if the count is less than A. 150,000/μL. B. 100,000/μL. C. 50,000/μL. D. 30,000/μL. - answers>>Answer: C Rationale: Platelets usually are given to correct thrombocytopenia if the platelet count is less than 20,000/μL or is less than 50,000/μL if the patient is actively bleeding. In a severely anemic patient, you expect to find A. dyspnea and tachycardia. B. cyanosis and pulmonary edema. C. cardiomegaly and pulmonary fibrosis. D. ventricular dysrhythmias and wheezing. - answers>>Answer: A Rationale: Patients with severe anemia (hemoglobin <6 g/dL) exhibit the following cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction; tachypnea, orthopnea, dyspnea at rest. In addition to altered red blood cells (RBCs), which laboratory finding does the nurse expect for the patient with sickle cell disease? A. Leukocytosis B. Hypouricemia C. Hyperbilirubinemia D. Hypercholesteremia - answers>>Answer: C Rationale: As a result of accelerated RBC breakdown, the patient may have characteristic clinical findings of hemolysis, including jaundice and elevated serum bilirubin levels. In non-Hodgkin's lymphoma, the involved cell in 90% of cases is the A. B lymphocyte. B. T lymphocyte. C. Reed-Sternberg cell. D. neutrophil. - answers>>Answer: A Rationale: In 90% of cases of non-Hodgkin's lymphoma, the B lymphocyte is the cell of origin. Multiple drugs are often used in combinations to treat leukemia and lymphoma because
one from a peripheral site and one from a venous access device should be done promptly. In the febrile, neutropenic patient, antibiotics should be started immediately (within 1 hour). Cultures of the nose, throat, sputum, urine, stool, obvious lesions, and the blood may be indicated. Ongoing febrile episodes or a change in the patient's assessment (or vital signs) requires a call to the physician to order additional cultures, diagnostic tests, and antimicrobial therapies. The blood bank notifies you that the two units of blood ordered for an anemic patient are ready for pick up. You should take which action to prevent an adverse effect during this procedure? A. Immediately pick up both units of blood from the blood bank. B. Infuse the blood slowly for the first 15 minutes of the transfusion. C. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. D. Set up the Y-tubing of the blood set with dextrose in water as the flush solution. - answers>>Answer: B Rationale: Because a transfusion reaction is more likely to occur at the beginning of a transfusion, you should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging a unit of blood. The care plan for a patient with aplastic anemia should include activities to minimize the risk for which complications? A. Dyspnea and pain B. Diarrhea and fatigue C. Nausea and malnutrition D. Infection and hemorrhage - answers>>Answer: D Rationale: You must assist the patient in reducing infection risk. The patient is susceptible to infection and is at risk for septic shock and death. Even a low-grade temperature (>100.4° F) should be considered a medical emergency. Thrombocytopenia manifests as a predisposition to bleeding evidenced by petechiae, ecchymosis, and epistaxis. Pain is not experienced nor is diarrhea. Nausea and malnutrition are not related to this disease except as a by-product of infection. The most common type of leukemia in older adults is A. acute myelocytic leukemia. B. acute lymphocytic leukemia. C. chronic myelocytic leukemia. D. chronic lymphocytic leukemia. - answers>>Answer: D Rationale: Chronic lymphocytic leukemia is a disease primarily found in older adults. The nursing management of a patient in sickle cell crisis includes (select all that apply) A. monitoring of the complete blood cell (CBC) count. B. blood transfusions if required and iron chelation. C. optimal pain management and oxygen therapy.
D. rest as needed and deep vein thrombosis prophylaxis. - answers>>Answer: A, B, C, & D Rationale: The CBC count is monitored. Infections are common with an elevated white blood cell (WBC) count, and anemia may occur with low hemoglobin and red blood cell (RBC) levels. Oxygen may be administered to treat hypoxia and control sickling. Rest may be instituted to reduce metabolic requirements and deep vein thrombosis prophylaxis (using anticoagulants) prescribed. Transfusion therapy is indicated when an aplastic crisis occurs. Patients may require iron chelation therapy to reduce transfusion- produced iron overload. Pain occurring during an acute crisis usually is undertreated. Patients should have optimal pain control with opioid analgesics, nonsteroidal antiinflammatory agents, antineuropathic pain medications, local anesthetics, or nerve blocks. The nursing student asks the clinical instructor to explain why clinical symptoms are more important than laboratory values when the patient has experienced blood loss. The instructor correctly recognizes that A. nurses should focus on clinical symptoms because those are the parameters of nursing practice. B. blood values are often normal or even high because fluid shifts have not occurred and laboratory values are falsely high. C. laboratory values are used to supplement nursing assessments. D. laboratory findings are often falsely low in the early period of blood loss. - answers>>Answer: B Rationale: It is essential to understand that the clinical signs and symptoms the patient is experiencing are more important than the laboratory values. For example, an adult with a bleeding peptic ulcer who had a 750-mL hematemesis (15% of a normal total blood volume) within the past 30 minutes may have postural hypotension but have normal hemoglobin and hematocrit values. Over the ensuing 36 to 48 hours, most of the blood volume deficit will be replaced by the movement of fluid from the extravascular into the intravascular space. Only at these later times will the hemoglobin and hematocrit values reflect the blood loss. The patient will receive desmopressin acetate (DDAVP) as a part of the treatment plan for mild hemophilia A. The nurse knows the drug is used to stimulate blood clotting factors and expects which outcome? A. Increased red blood cell count B. Decreased bleeding time C. Increased reticulocytes D. Increased platelets - answers>>Answer: B Rationale: Beneficial effects of DDAVP include decreased bleeding time. DDAVP does not increase levels of platelets, reticulocytes, or red blood cells. The primary pathophysiology underlying thalassemia is
When obtaining assessment data from a patient with a microcytic, hypochromic anemia, you question the patient about A. folic acid intake. B. dietary intake of iron. C. a history of gastric surgery. D. a history of sickle cell anemia. - answers>>Answer: B Rationale: Iron deficiency anemia is a type of microcytic, hypochromic anemia. When preparing to administer an ordered blood transfusion, you select which intravenous solution to use when priming the blood tubing? A. Lactated Ringer's B. 5% dextrose in water C. 0.9% sodium chloride D. 0.45% sodium chloride - answers>>Answer: C Rationale: The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. When providing care for a patient with thrombocytopenia, you instruct the patient to A. dab his or her nose instead of blowing. B. be careful when shaving with a safety razor. C. continue with physical activities to stimulate thrombopoiesis. D. avoid aspirin because it may mask the fever that occurs with thrombocytopenia. - answers>>Answer: A Rationale: Blowing the nose forcefully should be avoided; the patient should gently pat it with a tissue if needed. Patients with thrombocytopenia should avoid aspirin; aspirin reduces platelet adhesiveness, contributing to bleeding. Patients should not perform vigorous exercise or lift weights. If the patient is weak and at risk for falling, supervise the patient when out of bed. Patients should be instructed not to shave with a blade; an electric razor should be used. When providing teaching for the patient with iron-deficiency anemia who has been prescribed iron supplements, you should include taking the iron with which beverage? A. Milk B. Ginger ale C. Orange juice D. Water - answers>>Answer: C Rationale: Taking iron with vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid, also enhances iron absorption. Milk may interfere with iron absorption. Ginger ale and water do not facilitate iron absorption.
When reviewing the patient's hematologic laboratory values after a splenectomy, you would expect to find A. leukopenia. B. RBC abnormalities. C. decreased hemoglobin. D. increased platelet count. - answers>>Answer: D Rationale: Splenectomy can have a dramatic effect in increasing peripheral RBC, WBC, and platelet counts. Which assessment findings are consistent with thrombocytopenia? A. Petechiae, ecchymoses B. Pallor, spider angiomas C. Cyanosis, dullness D. Jaundice, purpura - answers>>Answer: A Rationale: Many patients with thrombocytopenia are asymptomatic. The most common symptom is bleeding, usually mucosal or cutaneous. Mucosal bleeding may manifest as epistaxis and gingival bleeding, and large bullous hemorrhages may appear on the buccal mucosa because of the lack of vessel protection by the submucosal tissue. Bleeding into the skin manifests as petechiae, purpura, or superficial ecchymoses Which finding allows you to identify the patient's anemia as folic acid deficiency rather than cobalamin deficiency? A. Loss of appetite B. Lack of neuromuscular symptoms C. Red tongue D. Change in nail shape - answers>>Answer: B Rationale: The absence of neurologic problems is an important diagnostic finding and differentiates folic acid deficiency from cobalamin deficiency. Which finding would you recognize as an indicator of chronic myelogenous leukemia (CML)? A. Presence of an abnormal LE cell B. Numerous immature lymphoblasts C. An elevated white blood cell count D. Presence of the Philadelphia chromosome - answers>>Answer: D Rationale: CML is caused by excessive development of mature neoplastic granulocytes in the bone marrow. The excess neoplastic granulocytes move into the peripheral blood in massive numbers and ultimately infiltrate the liver and spleen. These cells contain a distinctive cytogenetic abnormality, the Philadelphia chromosome, which serves as a disease marker and results from translocation of genetic material between chromosomes 9 and 22.
Which nursing intervention should you prioritize in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)? A. Administration of packed red blood cells B. Administration of clotting factors VIII and IX C. Administration of oral or intravenous corticosteroids D. Maintenance of reverse isolation and application of standard precautions - answers>>Answer: C Rationale: Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Which organ is at greatest risk due to the effects of hemolytic anemia? A. Heart B. Spleen C. Kidney D. Liver - answers>>Answer: C Rationale: For all causes of hemolysis, a major focus of treatment is to maintain renal function. When RBCs are hemolyzed, the hemoglobin molecule is released and filtered by the kidneys. The accumulation of hemoglobin molecules can obstruct the renal tubules and lead to acute tubular necrosis Which patient is most likely to experience anemia caused by increased destruction of RBCs? A. An African American man who has a diagnosis of sickle cell disease B. A 59-year-old man whose alcoholism has precipitated folic acid deficiency C. A 30-year-old woman with a history of "heavy periods" accompanied by anemia D. A 3-year-old child whose impaired growth and development is attributable to thalassemia - answers>>Answer: A Rationale: The cause of sickle cell anemia involves increased hemolysis. Thalassemias and folic acid deficiencies decrease erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss. Which points should be included in teaching the patient with sickle cell disease (select all that apply)? A. Avoid dehydration. B. Avoid high altitudes. C. Take cobalamin (vitamin B12) regularly. D. Consume dairy products frequently. E. Increase consumption of grapefruit juice. - answers>>Answer: A & B
Rationale: Avoiding dehydration and high altitudes helps to prevent crises. Vitamins, dairy products, and grapefruit juice cannot help the patient to prevent attacks of sickle cell disease. Which sign or symptom would you recognize as a unique characteristic specific to hemolytic anemia? A. Tachycardia B. Weakness C. Decreased RBCs D. Jaundice - answers>>Answer: D Rationale: Jaundice is likely because the increased destruction of RBCs causes an elevation in bilirubin levels. The spleen and liver may enlarge because of their hyperactivity, which is related to macrophage phagocytosis of the defective erythrocytes. The other symptoms are common to all types of anemia. Which statement made by a patient with hemophilia indicates a need for further teaching? A. "I will take aspirin to control pain." B. "I will avoid weight bearing until swelling has subsided." C. "I will increase wear a medic alert bracelet at all times." D. "I will stop any bleeding by applying direct pressure and ice to the area." - answers>>Answer: A Rationale: Aspirin should never be administered because it can prolong bleeding. All of the other interventions are appropriate and demonstrate understanding regarding self- care. You anticipate that a patient with von Willebrand's disease undergoing surgery will be treated with administration of von Willebrand factor (vWF) and A. thrombin. B. factor VI. C. factor VII. D. factor VIII. - answers>>Answer: D Rationale: Von Willebrand's disease involves a deficiency of the von Willebrand coagulation protein, variable factor VIII deficiencies, and platelet dysfunction. Treatment includes administration of vWF and factor VIII. You anticipate the onset of manifestations related to thalessemia to occur by A. 6 months of age. B. age 1 year. C. age 2 year. D. adolescence. - answers>>Answer: C
second most common; another finding is cheilitis (inflammation of the lips). The patient may report headache, paresthesias, and a burning sensation of the tongue, all of which are caused by lack of iron in the tissues. A sore tongue is a sign of cobalamin deficiency. Tenting skin is a sign of dehydration that often accompanies diarrhea. Blue mucous membranes are associated with cyanosis. You are evaluating the laboratory data of the patient with suspected aplastic anemia. Which findings support this diagnosis? A. Reduced RBCs, reduced white blood cells (WBCs), and reduced platelets B. Reduced RBCs, normal WBCs, and normal platelets C. Normal RBCs, reduced WBCs, and reduced platelets D. Elevated RBCs, increased WBCs, and increased platelets - answers>>Answer: A Rationale: Because all marrow elements are affected, hemoglobin, WBC, and platelet values are decreased in aplastic anemia. Other RBC indices usually are normal. You correctly identify which descriptions as characteristic of anemia of chronic disease (select all that apply) A. normocytic. B. normochromic. C. microcytic. D. hypochromic. E. proliferative. - answers>>Answer: A & B Rationale: Anemia of chronic disease, also called anemia of inflammation, is associated with an underproduction of RBCs and mild shortening of RBC survival. The RBCs are usually normocytic, normochromic, and hypoproliferative. The anemia is usually mild, but it can be more severe. You encourage the patient with cobalamin deficiency to seek treatment because untreated pernicious anemia may result in A. death. B. liver failure. C. heart failure. D. gastrectomy. - answers>>Answer: A Rationale: Regardless of how much cobalamin is ingested, the patient is not able to absorb it if intrinsic factor is lacking or if there is impaired absorption in the ileum. For this reason, increasing dietary cobalamin does not correct the anemia. However, the patient should be instructed about adequate dietary intake to maintain good nutrition (see Table 31-5). Parenteral (cyanocobalamin or hydroxocobalamin) or intranasal (Nascobal, CaloMist) administration of cobalamin is the treatment of choice. Without cobalamin administration, these individuals will die in 1 to 3 years. You expect which laboratory finding to be abnormal for a patient with hemochromatosis?
A. RBCs B. Platelets C. Iron D. Folic acid - answers>>Answer: C Rationale: The normal range for total body iron is 2 to 6 g. Individuals with hemochromatosis accumulate iron at a rate of 0.5 to 1.0 g each year and may exceed total iron concentrations of 50 g. The other values are near normal. You note a physician's order written at 10:00 AM for 2 units of packed red blood cells to be administered to a patient who is anemic secondary to chronic blood loss. If the transfusion is picked up at 11:30, you should plan to hang the unit no later than what time? A. 11:45 AM B. 12:00 noon C. 12:30 PM D. 3:30 PM - answers>>Answer: B Rationale: You must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank. You receive a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which procedure is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hand the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl. - answers>>Answer: A Rationale: The fresh frozen plasma should be administered as rapidly as possible and should be used within 2 hours of thawing. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion. Your primary goal in the care of the patient with DIC is to A. provide emotional support. B. recognize early signs of occult or overt bleeding. C. monitor nutritional intake. D. report abnormal laboratory results. - answers>>Answer: B Rationale: Early detection of occult and overt bleeding must be your primary goal. You should assess for signs of external bleeding such as petechiae, oozing at intravenous or injection sites, and signs of internal bleeding, such as increased heart rate, changes in mental status, or pain. Emotional support is important but is a secondary goal, as is
