ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 31 : Caring for Clients With Disorders of the Hematopoietic System Questions
Question 1 of 5
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?
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.
Question 2 of 5
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.
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.
Question 3 of 5
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.
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.
Question 4 of 5
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?
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.
Question 5 of 5
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?
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.