Chapter 55 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 55

Question 1

Type: MCMA

The nurse is developing a series of presentations for a group of high school students interested in a career in health care. Which topics would the nurse consider for inclusion in a discussion of hematologic function?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The hematologic system is a transport system that functions to provide nutrients to the body.

2. The main component of the hematologic system is blood.

3. The hematologic system is a transport system that functions to remove toxins from the body.

4. The lymphatic and the reticuloendothelial/mononuclear phagocyte systems contribute to the functions of the hematologic system.

5. Blood is a type of epithelial tissue.

Correct Answer: 1,2,3,4

Rationale 1: The hematologic system is a method of transport that delivers nutrition, oxygen, and secretory products throughout the body.

Rationale 2: Blood is the tissue that makes up the hematologic system.

Rationale 3: Blood transports wastes to the kidneys and liver for disposal.

Rationale 4: The lymphatic system, the spleen, the liver, and the reticuloendothelial/mononuclear phagocyte system contribute to the overall function of the hematologic system.

Rationale 5: Blood is a type of connective tissue that runs throughout the body.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 55-1

Question 2

Type: MCMA

Which statements would the nurse make when discussing age-related changes in the hematologic system?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. When you are past middle age, your hemoglobin levels will be slightly lower than when you were younger.

2. You have less red marrow than when you were younger, but will still have this important component even into old age.

3. As you continue to age, we will see big differences in your blood cell counts on lab tests.

4. You may not respond to immunizations as well because of changes in your cells related to the immune response.

5. It may take your body longer to return to the normal amount of blood cells if you are injured or get sick.

Correct Answer: 1,2,4,5

Rationale 1: Hemoglobin levels tend to decrease after middle age. This decrease is greater in men that in women.

Rationale 2: It is thought that the amount of red marrow decreases with aging, but that the marrow is not completely depleted even in very old adults.

Rationale 3: Laboratory parameters as they relate to the hematologic system of aging patients are usually not much different from those of a younger patient.

Rationale 4: It has been suggested that there may be some T-cell function loss and that this may account for a poor response to immunizations.

Rationale 5: The number of functioning stem cells decreases with aging, which reduces the bodys ability to respond to the need for

blood cells in the advent of injury or disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-1

Question 3

Type: MCMA

Which patient statements would the nurse document as part of the chief complaint?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. My father had sickle cell anemia.

2. All I want to do is sleep. I am tired all the time.

3. I get short of breath so easily.

4. I lived in a city where there was a lot of pollution when I was a child.

5. I cant seem to recover from the cold I had last month.

Correct Answer: 2,3,5

Rationale 1: This statement reveals family history but does not describe the patients current issue. It is not a chief complaint.

Rationale 2: This statement describes a problem the patient is experiencing and is considered a chief complaint.

Rationale 3: The statement describes a problem the patient is experiencing and is considered a chief complaint.

Rationale 4: This statement is part of the patients historical data, not a chief complaint.

Rationale 5: Although this statement seems to be historical in that it refers to a cold last month, it actually describes a chief complaint. The patient is reporting a current inability to recover from that cold.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 4

Type: MCMA

What phrases would the nurse use to describe red blood cells?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Are formed from monoblasts

2. Maintain the chemical integrity of hemoglobin

3. Have a life span of approximately 90 days

4. Carry oxygen to tissues

5. Assume a rigid disk shape when filled with hemoglobin

Correct Answer: 2,4

Rationale 1: Red blood cells are formed from erythroblasts. Monoblasts form monocytes, a type of white blood cell.

Rationale 2: The function of the red blood cells is to become filled with hemoglobin, maintain the integrity of hemoglobin, and distribute it to the bodys tissues.

Rationale 3: The actual life span of a red blood cell is approximately 120 days.

Rationale 4: The red blood cells primary function is to be filled with hemoglobin, which carries oxygen to the tissues.

Rationale 5: Red blood cells assume a flexible disk shape that allows for optimal filling and ease of transport to body tissues through the

circulatory system.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-2

Question 5

Type: MCMA

A patient is admitted to the unit with a high count of lymphocytes. The nurse knows that a greater number of which types of cells are present?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Thrombocytes

2. Natural killer cells (NK cells)

3. Reticulocytes

4. T cells

5. B cells

Correct Answer: 2,4,5

Rationale 1: Thrombocytes are platelets and are not included in the lymphocyte count.

Rationale 2: Natural killer cells (NK cells) are a type of lymphocyte that would be included in this count.

Rationale 3: Reticulocytes are precursors to erythrocytes and are not included in this count.

Rationale 4: Approximately 60% to 70% of blood lymphocytes are T cells.

Rationale 5: Approximately 10% of blood lymphocytes are B cells.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-2

Question 6

Type: MCSA

A patient with a family history of anemia is admitted to the unit. What type of blood cell would be characteristic of an anemia with a familial pattern?

1. Eosinophil

2. Sickle cell

3. Lymphocyte

4. Reticulocyte

Correct Answer: 2

Rationale 1: Eosinophils are normal cells present in the blood.

Rationale 2: The sickle cell is an abnormal cell, shaped like a sickle, and is unique to sickle cell anemia, which has a familial pattern.

Rationale 3: Lymphocytes are normal cells present in blood.

Rationale 4: Reticulocytes are normal cells present in blood.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-2

Question 7

Type: MCMA

How would the nurse explain primary and secondary hemostasis to the parents of a child newly diagnosed with a platelet disorder?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. During primary hemostasis, the vessels around the injured area constrict to reduce blood loss.

2. The clot that forms in the injured vessel becomes more stable during secondary hemostasis.

3. Normally a soft plug or clot is formed early in primary hemostasis.

4. Normally, the coagulation cascade is started in primary hemostasis.

5. Platelets play a role in primary hemostasis.

Correct Answer: 1,2,3,5

Rationale 1: Primary hemostasis is characterized by vascular contraction, platelet adhesion, and formation of a soft aggregate plug.

Rationale 2: During secondary hemostasis, the soft clot that is normally formed in the primary phase is stabilized.

Rationale 3: Platelets normally form a soft plug or clot at the site of injury early in primary hemostasis.

Rationale 4: The coagulation cascade initiates secondary hemostasis.

Rationale 5: Primary hemostasis is characterized by platelet adhesion.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-1

Question 8

Type: MCMA

Physical examination related to the hematologic system of the adult patient should include inspection of which areas of the body?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Skin

2. Chest

3. Head and neck

4. Feet and leg musculature

5. Abdomen

Correct Answer: 1,2,3,5

Rationale 1: Changes in skin color often indicate erythrocyte disorders such as anemia.

Rationale 2: Structures in the chest, heart, and lymph nodes yield clues to hematologic system disorders; for example, tachycardia is a response to both infection and anemia.

Rationale 3: The structures of the head, particularly the eyes and mouth, provide useful evidence in the evaluation of the patient. The neck should be inspected for signs of lymph node enlargement or tenderness.

Rationale 4: Assessment of feet and leg musculature does not provide any specific clues to hematologic problems.

Rationale 5: Abdominal tenderness is a general complaint that might be indicative of splenomegaly or hepatomegaly, both indicators of increased blood destruction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 9

Type: MCSA

The nurse asks specific questions about alcohol consumption when collecting data about a patients hematologic system. What rationale would the nurse offer for these questions?

1. Excessive alcohol intake accelerates phagocytosis.

2. People who consume excessive amounts of alcohol often have vitamin deficiencies.

3. People who drink alcohol do not clot as well as those who do not.

4. Moderate alcohol consumption can help to accelerate erythrocyte formation.

Correct Answer: 2

Rationale 1: Alcohol does not affect phagocytosis.

Rationale 2: Excessive alcohol use results in vitamin deficiencies and potentially GI damage that can suppress hematopoiesis.

Rationale 3: Alcohol does not dramatically affect clotting.

Rationale 4: Alcohol consumption does not affect erythrocyte formation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 10

Type: MCMA

When assessing an older adult for possible hematologic problems, the nurse should pay particular attention to which portions of the assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. General physical appearance

2. Laboratory parameters

3. Presence of risk factors

4. Presenting symptoms and chief complaint

5. History of bleeding problems

Correct Answer: 1,3,4,5

Rationale 1: General physical appearance conveys an impression of health status in patients of all ages.

Rationale 2: There is usually not much difference in the laboratory parameters of aging patients and younger patients.

Rationale 3: Assessment of risk factors is important in all ages, but aging may make some risk factors more significant.

Rationale 4: Presenting symptoms and chief complaint tell the nurse in the patients own words what is wrong and alert the nurse to potential foci of current problems, for example, RBCs or WBCs.

Rationale 5: A history of bleeding problems provides clues as to possible current problems.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 11

Type: MCSA

A middle-aged couple has had their hemoglobin and hematocrit levels measured at a community health fair. How would the nurse explain the results of these tests?

1. Hemoglobin values vary between men and women, but hematocrit values do not.

2. Hemoglobin is the percentage of iron-carrying protein in a standard volume of blood, whereas hematocrit is an indicator of the amount of that protein in a red blood cell.

3. Normal hematocrit values are about 3 times the hemoglobin value.

4. Hemoglobin can change quickly due to dehydration.

Correct Answer: 3

Rationale 1: Hematocrit levels do vary between men and women.

Rationale 2: Hemoglobin is the amount of functional or iron-carrying protein in the red blood cell. Hematocrit is reported as a percentage of hemoglobin present in a given volume of whole blood.

Rationale 3: Hematocrit level can be estimated by multiplying the hemoglobin by 3.

Rationale 4: Hematocrit is affected by hydration status; hemoglobin is not.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-4

Question 12

Type: MCSA

A differential blood count has been ordered on a patient being admitted for surgery. How would the nurse explain the purpose of this test?

1. This test will measure your clotting ability before you are taken to surgery.

2. This test measures the total number of white blood cells.

3. This test assesses whether you have responded to the blood transfusion you received last week.

4. This test measures percentages of the different white blood cells to help us determine if you have an infection.

Correct Answer: 4

Rationale 1: The number of thrombocytes in whole blood is measured by a platelet count, not a differential.

Rationale 2: A white blood cell count is ordered to assess total number of white blood cells.

Rationale 3: The test to measure response to blood transfusion is a hemoglobin and hematocrit.

Rationale 4: The differential count measures the percentages of different types of white blood cells in the blood sampleneutrophils, lymphocytes, monocytes, eosinophils, and basophils. These percentages help the health care providers determine if infection is present.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-5

Question 13

Type: MCMA

The patients laboratory testing reveals a decreased red blood cell count. The nurse anticipates further testing to determine if the patient has which disorder?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Polycythemia vera

2. Bleeding

3. Lack of hormone needed to produce leukocytes

4. Bone marrow suppression

5. Abnormal destruction of erythrocytes

Correct Answer: 2,4,5

Rationale 1: Polycythemia vera is an overproduction of erythrocytes and is not characterized by a low red blood cell count.

Rationale 2: Bleeding causes abnormal loss of erythrocytes, resulting in a low red blood cell count.

Rationale 3: Leukocytes are white blood cells, so a lack of hormones to produce leukocytes would not affect a red blood cell count.

Rationale 4: Red blood cells are formed in the bone marrow, so suppression would cause fewer cells to be produced.

Rationale 5: If erythrocytes are being destroyed abnormally, the red blood cell count will drop.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-5

Question 14

Type: MCMA

A patients laboratory values indicate a shift to the left. The nurse would anticipate further testing for which possible conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Bone marrow disease

2. Undetected infection

3. Presence of foreign cells in the bone marrow

4. Immune system insufficiencies

5. Expected response to immunosuppressive therapies

Correct Answer: 1,2,4,5

Rationale 1: A shift to the left may be indicative of bone marrow disease.

Rationale 2: A shift to the left is a compensatory mechanism to combat infection.

Rationale 3: A shift to the left is not indicative of foreign cells in the marrow.

Rationale 4: A shift to the left may be indicative of immune system insufficiencies caused by bone marrow disease.

Rationale 5: A shift to the left may occur as a result of immunosuppressive therapies such as chemotherapy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 55-6

Question 15

Type: MCSA

A patients laboratory values indicate a shift to the left. The nurse would expect changes in which cell count?

1. Platelets

2. White blood cell count

3. Erythrocytes

4. Absolute neutrophil count (ANC)

Correct Answer: 2

Rationale 1: Changes in platelets are not described as a shift to the left.

Rationale 2: A shift to the left represents an increase in the total white blood cell count. The bone marrow is stimulated to release a large number of relatively immature cells and juvenile cells as a compensatory mechanism to combat severe infection.

Rationale 3: Changes in erythrocytes are not described as a shift to the left.

Rationale 4: Changes in ANC are not described as a shift to the left.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-6

Question 16

Type: MCSA

The nurse would immediately collaborate with the health care provider if a patient experiences a shift to the left in laboratory values. What is the rationale for this collaboration?

1. This shift is an indicator of electrolyte imbalance.

2. This shift is an indicator of disruption of hemostasis.

3. This shift is an indicator of a potential bleeding problem.

4. This shift is an indicator of risk for a severe infection.

Correct Answer: 4

Rationale 1: A shift to the left does not pertain to electrolyte imbalance.

Rationale 2: A shift to the left does not pertain to hemostasis disruption.

Rationale 3: A shift to the left does not pertain to potential bleeding problems.

Rationale 4: In a shift to the left, the bone marrow is stimulated to release a large number of relatively immature and juvenile cells as a compensatory mechanism to combat severe infection. In an otherwise healthy individual, this may signal an early sign of an otherwise undetected infection, and the patient may not have sufficient host defenses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-6

Question 17

Type: MCSA

While reviewing the white blood cell count differential for a patient, the nurse notes that the basophil count is elevated. What does this laboratory value indicate to the nurse?

1. The patient is experiencing an acute hypersensitivity reaction.

2. The patient has a parasitic infection.

3. The patient is fighting chronic infection.

4. The patient is fighting cancer.

Correct Answer: 1

Rationale 1: Basophils release heparin, histamine, and other inflammatory mediators into the bloodstream. They play an exceedingly important role in allergic reactions.

Rationale 2: Eosinophils are thought to be responsible for protecting the body from parasites.

Rationale 3: Monocytes and macrophages activate the immune response against chronic infections.

Rationale 4: There is no specific connection between increased basophils and the presence of cancer.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-6

Question 18

Type: MCSA

A patients white blood cell count is 11,000/mm3. The nurse evaluates this value as representing which component of the hematologic system?

1. The total number of circulating leukocytes

2. The total number of circulating neutrophils

3. The total number of circulating eosinophils

4. The total number of circulating basophils

Correct Answer: 1

Rationale 1: In laboratory tests, the WBC count indicates the total number of circulating leukocytes.

Rationale 2: The differential identifies the total number of circulating neutrophils.

Rationale 3: The differential identifies the total number of circulating eosinophils.

Rationale 4: The differential identifies the total number of circulating basophils.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-4

Question 19

Type: MCSA

A patient comes to the emergency department complaining of dyspnea. After analyzing these laboratory results, the nurse would conduct further assessment for which condition?

1. Pancytopenia

2. Chronic bacterial infection

3. A respiratory infection

4. A hypersensitivity response

Correct Answer: 4

Rationale 1: Pancytopenia would be indicated by very low levels of the laboratory values.

Rationale 2: The patient with a chronic bacterial infection would have an increased WBC count.

Rationale 3: The patient with a respiratory infection would have an increased WBC count.

Rationale 4: The eosinophils (normal 13%) and basophils (0.4%1%) are involved in hypersensitivity responses. The lab values and dyspnea suggest a hypersensitivity response.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-5

Question 20

Type: MCSA

A patients laboratory results reveal a low platelet count. The nurse would assess the patient for which skin finding?

1. Jaundice

2. Petechiae

3. A brown or dark tinge to the skin

4. A flushed appearance

Correct Answer: 2

Rationale 1: Jaundice is generally related to liver failure.

Rationale 2: Petechiae are small capillary bleeds that manifest as red dots on the skin. Petechiae can result from bleeding disorders caused by reduced platelets.

Rationale 3: Brown or darker skin than normal may indicate a breakdown of erythrocytes. This is not associated with platelet dysfunction.

Rationale 4: Pink or flushed skin may be caused by polycythemia vera.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 21

Type: MCSA

A patients mean corpuscular volume (MCV) is low. How would the nurse explain this finding to the patient?

1. Your red blood cells do not have enough hemoglobin.

2. Your red blood cells are not consistent in size.

3. Your hematocrit is low.

4. Your red blood cells are small.

Correct Answer: 4

Rationale 1: Mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) are tests for the amount of hemoglobin in a red blood cell.

Rationale 2: The red blood cell distribution width (RDW) is a direct measure of the consistency of red blood cell size.

Rationale 3: MCV is not a measure of hematocrit. Hematocrit changes with hydration status, so it is not possible to correlate hematocrit level and MCV.

Rationale 4: MCV is a measure of the size of red blood cells.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-5

Question 22

Type: MCSA

The patient is scheduled to have a mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) drawn. How would the nurse explain the purpose of these tests?

1. These tests will help us determine if you have cancer in your blood.

2. We are testing to see if you have an infection.

3. These tests will help us determine what kind of anemia you have.

4. We are testing to see if you have anemia.

Correct Answer: 3

Rationale 1: These tests are not used to detect cancer in the blood.

Rationale 2: These tests are not used to detect infection.

Rationale 3: MCV, MCH, and MCHC are used to help determine type of anemia.

Rationale 4: The total red blood cell count would indicate if anemia is present.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-4

Question 23

Type: MCSA

A patient has just had a bone marrow biopsy taken from the iliac crest. What is the nurses next action?

1. Apply a fluid collection device around the drain.

2. Cover the biopsy site with a bulky pressure dressing.

3. Plan to assess the patient regularly for pain and bleeding.

4. Have the patient ambulate to mobilize marrow replacement.

Correct Answer: 3

Rationale 1: A drain is not inserted in this procedure.

Rationale 2: There is no need to use a bulky dressing over this site. A small gauze square is applied with mild pressure.

Rationale 3: The nurse should assess this patient regularly for pain and bleeding.

Rationale 4: There is no specific need to have the patient ambulate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-4

Question 24

Type: MCSA

A patient diagnosed with sickle cell anemia is in severe pain. How would the nurse explain the etiology of this pain?

1. You dont have enough red blood cells to carry oxygen to your tissues.

2. You have infection in your blood because your white blood cells are not working correctly.

3. Your red blood cells clog up the vessels and the tissues dont get oxygen.

4. You have too many red cells, so your blood is too thick.

Correct Answer: 3

Rationale 1: The major etiology of pain in sickle cell anemia is not related to a decreased number of red blood cells.

Rationale 2: Sickle cell anemia is not related to changes in the white blood cells.

Rationale 3: Because of their sickled shape, the RBCs occlude vessels, causing ischemia to the tissues being supplied by the vessels. Ischemia results in pain.

Rationale 4: The pathology of sickle cell anemia does not include excess of red blood cells.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-2

Question 25

Type: MCSA

Which chief complaint would the nurse evaluate as indicating the patient may have problems with erythrocyte levels?

1. I have been running a low-grade fever for a week.

2. I have bruises all over my body.

3. I am sick all the time.

4. I am so tired all the time.

Correct Answer: 4

Rationale 1: Fever is more closely associated with leukocytes.

Rationale 2: Bruising is associated with a dysfunction of platelets.

Rationale 3: Frequent illnesses may reflect a dysfunction of leukocytes.

Rationale 4: Fatigue is often associated with changes in erythrocyte level.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 26

Type: MCSA

A patient reports that she has decided to follow a vegetarian diet. The nurse would discuss methods of obtaining enough of which important element in the diet?

1. Calories

2. Iron

3. Fat

4. Protein

Correct Answer: 2

Rationale 1: Vegetarian diets have sufficient calories.

Rationale 2: Many of the sources of iron in the diet are meat-based. A person following a vegetarian diet must be certain to obtain sufficient iron.

Rationale 3: Vegetarian sources of fat include vegetable oils and nuts.

Rationale 4: Vegetarian diets make use of plant-based proteins, eggs, and dairy products.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-2

Question 27

Type: MCSA

A patient with a lung disease takes prophylactic antibiotics and tries to stay indoors during the winter. Today the patient reports bleeding more than normal after a minor injury. How would the nurse evaluate this report?

1. The antibiotic may be interfering with clotting times.

2. The patient is not getting enough vitamin D from sunlight.

3. The patient may be ingesting more vitamin Kcontaining food.

4. The patients lung disease has affected the production of platelets.

Correct Answer: 1

Rationale 1: Some people develop prolonged bleeding times while taking antibiotics.

Rationale 2: Insufficient vitamin D is not the likely reason for this bleeding.

Rationale 3: Vitamin K is an antidote for warfarin and can cause increased clotting, not increased bleeding.

Rationale 4: There is no indication that lung disease reduces platelet production. It may, however, increase erythrocyte production.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 28

Type: MCSA

A patient is suspected of having pernicious anemia. Which area of the body would the nurse pay particular attention to during assessment?

1. Nose

2. Tongue

3. Hands

4. Feet

Correct Answer: 2

Rationale 1: The nose does not change when pernicious anemia is present.

Rationale 2: The tongue takes on a characteristic smooth texture when pernicious anemia is present.

Rationale 3: There is no particular change in the hands associated with pernicious anemia.

Rationale 4: There is no particular change in the feet associated with pernicious anemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-3

Question 29

Type: MCSA

The nurse is reviewing laboratory results for a 45-year-old woman. Which result would the nurse immediately discuss with the health care provider?

1. Hemoglobin 10.8 g/dL

2. Mean corpuscular volume 89m3

3. Mean corpuscular hemoglobin 30 pg

4. Total RBC 4,500,000 cells per cubic millimeter

Correct Answer: 1

Rationale 1: Normal hemoglobin for an adult woman is 1215 g/dL. The nurse should immediately discuss this low result with the health care provider.

Rationale 2: This is a normal MCV level.

Rationale 3: This is a normal MCH.

Rationale 4: This is a normal total RBC for an adult woman.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 55-5

Question 30

Type: MCSA

A patient is scheduled for a bone marrow aspiration. The nurse would reinforce which teaching about this procedure?

1. Bone marrow fluid will be drawn into a needle.

2. The sample will be taken from a vertebra in the neck.

3. Bone marrow fluid and a piece of bone will be collected.

4. The patient will receive general anesthesia for this procedure.

Correct Answer: 1

Rationale 1: Bone marrow aspiration includes collection of fluid through a needle.

Rationale 2: The sample is generally taken from the iliac crest.

Rationale 3: If bone is collected, the procedure is a bone marrow biopsy.

Rationale 4: This procedure is performed under local anesthesia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 55-5

 

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