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Hematology Answers and Rationale

1)  Answer: A. Eggs

One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes.

Options B and C: Dark green leafy vegetables and citrus fruits are good sources of vitamin C.

Option D: Cheese is a good source of calcium.

2)  Answer: C. Meats and dairy products

Good sources of vitamin B12 include meats and dairy products.

Option A: Whole grains are a good source of thiamine.

Option B: Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A).

Option D: Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).

3)  Answer: D. Folate, 1.5 ng/mL

The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol.

Options A, B, and C: The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.

4)  Answer: B. Intrinsic factor, absent.

The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the

Option A: Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract.

Option C: A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias.

Option D: An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.

5)  Answer: B. Avoid exposure to others with acute infection

Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance.

Option A: Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet.

Option C: Yoga and meditation are good complimentary therapies to reduce stress.

Option D: Eight hours of rest and naps are good for spacing and pacing activity and rest.

6)  Answer: D. “I take a vitamin B12 tablet every day.”

Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed.

Option A: Replacement of fluids and electrolytesis important when the client has continuous multiple loose stoolson a daily basis.

Option B: Warm salt water is used to soothe sore mucous membranes.

Option C: Crohn’s disease and small bowel resection may cause several loose stoolsa day.

7)  Answer: C. Drinks coffee or tea with meals

Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron.

Option A: Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source.

Option B: Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet.

Option D: Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

8)  Answer: A. “What activities were you able to do 6 months ago compared with the present?”

It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client’s activity tolerance by asking the client to compare activities 6 months ago and at the present.

Option B: Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client’s activity tolerance. Also, the client may not even identify that a “problem” exists.

Option C: Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance.

Option D: Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.

9)  Answer: C. Absorb vitamin B12

Pernicious anemia is caused by the body’s inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling’s test helps diagnose pernicious anemia by determining the client’s ability to absorb vitamin B12.

10)  Answer: B. Starting a 24- to 48 hour urine specimen collection

Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of non-radioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces.

Option A: Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12.

Option C: The client is NPO 8 to 12 hours before the test but is not NPO during the test.

Option D: A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered.

11)  Answer: B. “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor.”

Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine.

Options A, C, and D: The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.

12)  Answer: B. Respiratory rate decreased by 5 breaths/minute

The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange.

Option A: The post activity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity.

Option C: The diastolic blood pressureis expected to rise but by no more than 15 mm Hg.

Option D: The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

13)  Answer: C. Continue to monitor vital signs

The nurse should continue to monitor the client, because this value reflects a normal physiologic response. Immediately after surgery, the client’s hematocrit reflects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the client’s hematocrit level is more reflective of the amount of RBCs in the plasma.

Option A: Fresh bleedingis a less likely occurrence on the third post-op day but is not impossible; however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit.

Options B and D: The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings.

14)  Answer: A. Hematocrit

Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked.

Options B, C, and D: The PTT, hemoglobin level, and PT are not monitored for this drug.

15)  Answer: D. “Vitamin B12 is generally free of toxicity because it is water soluble.”

Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body’s needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations.

Options A, B, and C: Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration.

16)  Answer: B. Brown rice

Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non heme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes.

Option A: Egg yolks have iron but it is not as well absorbed as iron from other sources.

Option C: Vegetables are a good source of vitamins that may facilitate iron absorption.

Option D: Tea contains tannin, which combines with nonheme iron, preventing its absorption.

17)  Answer: B. Check for diminished sensations

Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain.

Option A: The burn could be related to abuse, but this conclusion would require more supporting data.

Option C: The findings should be documented, but the nurse would want to address the client’s sensations first.

Option D: The decision of how to treat the burn should be determined by the physician.

18)  Answer: C. Pruritus

Pruritus is a late symptom that results from abnormal histamine metabolism.

Options A and B: Headache and dizziness are early symptoms from engorged veins.

Option D: Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.

19)  Answers: B, C, D, E.

Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe).

Options A and F: Hearingloss and weight loss are not manifestations associated with polycythemia vera.

20)  Answer: A. Bleedingtendencies

Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies.

Option B: A change in the intake and output is important, but assessment for the potential for bleedingtakes priority.

Option C: Change in the peripheral nervous systemis a priority problem specific to clients with vitamin B12 deficiency.

Option D: Change in bowel function is not associated with aplastic anemia.

21)  Answer: A. Erythrocytes

Anemia is defined as a decreased number of erythrocytes (red blood cells).

Option B: Granulocytopenia is a decreased number of granulocytes (a type of white blood cells).

Option C: Leukopenia is a decreased number of leukocytes (white blood cells).

Option D: Thrombocytopenia is a decreased number of platelets.

22)  Answer: C. Oxygen

Anemia stems from a decreased number of red blood cells and the resulting deficiency in oxygen and body tissues. Clotting factors, such as factor VIII, relate to the body’s ability to form blood clots and aren’t related to anemia, not is carbon dioxide of T antibodies.

23)  Answer: C. Stem cell

The precursor to the RBC is the stem cell. B cells, macrophages, and T cells and lymphocytes, not RBC precursors.

24)  Answer: A. None

Mild anemia usually has no clinical signs. Palpitations, SOB, and pallor are all associated with severe anemia.

25)  Answer: B. Decreased levels of white blood cells, red blood cells, and platelets

In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia).

Option A: T-helper cell production doesn’t decrease in aplastic anemia.

Option D: Reed-Sternberg cells and lymphnode enlargement occur with Hodgkin’s disease.

26)  Answer: D. “Take the medication on an empty stomach.”

Preferably, ferrous gluconate should be taken on an empty stomach.

Options A, B, and C: Ferrous gluconate should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.

27)  Answer: C. Hemophilia A

Hemophilia A results from a deficiency of factor VIII.

Option A: Sickle cell disease is caused by a defective hemoglobin molecule.

Option B: Christmas disease, also called hemophilia B, results in a factor IX deficiency.

28)  Answer: C. Obstruction to circulation

Characteristic sickle cells tend to cause “log jams” in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis.

Option A: Sickle cell disease is an inherited disease, not an autoimmune reaction.

Option B: The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid.

Option D: Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

29)  Answer: D. “The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth.”

Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin.

Option A: The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta.

Option B: Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester.

Option C: Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.

30)  Answer: C. Pain related to tissue anoxia

For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusion and subsequent tissue ischemia.

Option A: Although ineffective copingmay be important, it is not the priority.

Option B: Decreased cardiac outputis not a problem with this type of vaso occlusive crisis.

Option D: Typically, a sickle cell crisis can be precipitated by a fluid volume deficitor dehydration.

31)  Answer: B. Children with iron deficiency anemia are more susceptible to infection than are other children.

Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

32)  Answers: A,B.

Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients.

33)  Answer: B. Potato, peas, and chicken

Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.

34)  Answer: D. Partial thromboplastin time (PTT)

PTT measures the activity of thromboplastin, which is dependent on intrinsic clottingfactors. In hemophilia, the intrinsic clotting factor VIII (antihemophilic factor) is deficient, resulting in a prolonged PTT.

Option A: Bleedingtime reflects platelet function.

Option B: the tourniquet test measures vasoconstriction and platelet function.

Option C: Clot retraction test measures capillary fragility. All of these are unaffected in people with hemophilia.

35)  Answer: A. Child’s reluctance to move a body part

Bleeding into the joints in the child with hemophilia leads to pain and tenderness, resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child’s reluctance to move a body part.

Option B: If the bleeding into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy.

Option C: Ecchymosis formation around a joint would be difficult to assess.

Option D: Instability of a long bone on passive movement is not associated with joint hemarthrosis.

36)  Answer: A. Yellowing of the skin

Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera.

Options B, C, and D: Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes.

37)  Answer: C. Reticulocyte count

A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

Options A, B, and D: Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated red blood cells.

38)  Answer: C. Fluid overload

Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.

39)  Answer: D. Red blood cells that are microcytic and hypochromic

The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

40)  Answer: D. Hemophilia A results from a deficiency of factor VIII

Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX.

Option A: Hemophilia is inherited in a recessive manner via a genetic defect on the X-chromosome.

Options B and C: Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers.

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