Chapter 17: Hematological and Immune Disorders

Sole: Introduction to Critical Care Nursing, 7th Edition

Multiple Choice

1. Of the four major blood components, plasma a. is made up of circulating ions. b. comprises about 55% of blood volume. c. is transported to the cells by serum proteins. d. comprises about 45% of blood volume.

ANS: B

Blood has four major components: (1) a fluid component called plasma, (2) circulating solutes such as ions, (3) serum proteins, and (4) cells. Plasma comprises about 55% of blood volume and is the transportation medium for important serum proteins such as albumin, globulin, fibrinogen, prothrombin, and plasminogen. The hematopoietic cells comprise the remaining 45% of blood volume.

DIF: Cognitive Level: Remember/Knowledge REF: p. 441

OBJ: Explain the normal anatomy and physiology of the hematological and immune systems. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

2. Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called a. erythropoietin. b. a reticulocyte. c. hemoglobin. d. 2,3-DPG

ANS: C

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Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called hemoglobin. RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature.

DIF: Cognitive Level: Remember/Knowledge REF: p. 441

OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

3. Erythrocytes (RBCs) are generated from precursor stem cells under the influence of a growth factor called a. reticulocytes. b. hemoglobin. c. 2,3-DPG. d. erythropoietin.

ANS: D

RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The RBC transports hemoglobin, whose function is the transport of oxygen and carbon dioxide. Hemoglobin binds with oxygen in the lungs and transports it to the tissues. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature.

DIF: Cognitive Level: Remember/Knowledge REF: p. 441

OBJ: Explain the normal anatomy and physiology of the hematological and immune systems. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

4. The nurse is caring for a patient who has undergone a splenectomy and notices that the patient’s platelet count has increased. The nurse realizes that the increase is due to a. platelet response to infection. b. stimulation secondary to erythropoietin. c. the patient’s inability to store platelets. d. the platelet’s 120-day life cycle.

ANS: C

Two thirds of the platelets circulate in the blood. The spleen stores the remaining third and may become enlarged if excess or rapid platelet removal occurs. In patients who have had a splenectomy, 100% of the platelets remain in circulation. Platelets are the first responders in the clotting response (not infection), and they form a platelet plug that temporarily repairs an injured vessel. RBCs (not platelets) are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Platelets have a life span of 8 to 12 days, but they may be used more rapidly if there are many vascular injuries or clotting stimuli. Maturation of RBCs takes 4 to 5 days, and their life span is about 120 days.

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DIF: Cognitive Level: Understand/Comprehension

REF: p. 444

OBJ: Explain the normal anatomy and physiology of the hematological and immune systems. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

5. The nurse examines the patient’s complete blood count with differential analysis and notices that the patient’s neutrophils are elevated but that the lymphocytes are lower than normal. The drop in lymphocyte count in the differential is most likely due to a. the increase in neutrophil count. b. a new viral infection. c. a decreased number of “bands.” d. the lack of immature neutrophils.

ANS: A

The differential count measures the percentage of each type of white blood cell (WBC) present in the venous blood sample, the total adding up to 100%. If the percentage of one type of WBC goes up (neutrophil count), the percentage of the remaining WBCs must go down as a result of the mathematical function of the differential. An elevation in the neutrophil count usually indicates a bacterial infection. “Bands” are immature neutrophils. The phrase “a shift to the left” refers to an increased number of “bands,” or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report. This finding generally indicates an acute bacterial infectious process (not viral) that draws on the WBC reserves in the bone marrow and causes less mature forms to be released.

DIF: Cognitive Level: Understand/Comprehension

REF: pp. 446-447

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

6. The nurse is caring for a patient receiving chemotherapeutic agents and notices that the patient’s neutrophil count is low. The nurse realizes that a. the patient has a bacterial infection. b. a shift to the left is occurring. c. chemotherapeutic agents alter the ability to fight infection. d. neutrophils have a long life span and multiply slowly.

ANS: C

The survival time of neutrophils is short. When serious infection is present, neutrophils may live only hours as the neutrophils phagocytize infectious organisms.Because of this short life span, drugs that affect rapidly multiplying cells (e.g., chemotherapeutic agents) quickly decrease the neutrophil count and alter the patient’s ability to fight infection. An elevation in the neutrophil count usually indicates a bacterial infection. “Bands” are immature neutrophils. The phrase “a shift to the left” refers to an increased number of “bands,” or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report.

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DIF: Cognitive Level: Remember/Knowledge REF: p. 445

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

7. When examining the patient’s laboratory values, the nurse notices an elevation in the eosinophil count. The nurse realizes that eosinophils become elevated a. with acute bacterial infections. b. in response to allergens and parasites. c. when the spleen is removed. d. in situations that do not require phagocytosis.

ANS: B

An elevation in the neutrophil count (not eosinophil count) usually indicates a bacterial infection. Eosinophils are important in the defense against allergens and parasites and are thought to be involved in the detoxification of foreign proteins. Eosinophils are found largely in the tissues of the skin, lung, and gastrointestinal tract (not the spleen). Eosinophils respond to chemotactic mechanisms triggering them to participate in phagocytosis.

DIF: Cognitive Level: Remember/Knowledge REF: p. 445

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

8. Although monocytes may circulate for only 36 hours, they can survive for months or even years as tissue macrophages. Monocytes found in the liver are called a. alveolar macrophages. b. Kupffer’s cells. c. histiocytes. d. monokines.

ANS: B

Monocytes are the largest of the leukocytes and constitute only 3% to 7% of the WBC differential. Once they migrate from the bloodstream into the tissues, monocytes mature into tissue macrophages, which are powerful phagocytes. In the lung, these tissue macrophages are known as alveolar macrophages; in the liver, they are Kupffer’s cells; in connective tissue, they are histiocytes. When activated by antigens, macrophages secrete substances called monokines that act as chemical communicators between the cells involved in the immune response.

DIF: Cognitive Level: Remember/Knowledge REF: p. 445

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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9. Lymphocytes are made up of B cells and T cells. B cells a. mature in lymphoid tissue. b. mediate humoral immunity. c. migrate to the thymus gland. d. destroy virus-infected cells.

ANS: B

Lymphocytes are responsible for specific immune responses and participate in two types of immunity: (1) humoral immunity, which is mediated by B lymphocytes, and (2) cellular immunity, which is mediated by T lymphocytes. B lymphocytes, or B cells, originate in the bone marrow and are also thought to mature there. B cells perform in antibody production. T cells are produced in the bone marrow, but they migrate to the thymus for maturation; then, most of them travel and reside in lymphoid tissues throughout the body. They live longer than B cells and participate in long-term immunity. The natural killer cell is a third type of lymphocyte, thought to be a differentiated form of the T lymphocyte. It is responsible for surveillance and destruction of virus-infected and malignant cells.

DIF: Cognitive Level: Remember/Knowledge REF: p. 446

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

10. The process by which the body actively produces cells and mediators that result in the destruction of the antigen is called a. passive immunity. b. active immunity. c. autoimmunity. d. recognition of self as nonself.

ANS: B

Active immunity is a term used when the body actively produces cells and mediators that result in the destruction of the antigen. Passive immunity is that which is transferred from another person (e.g., maternal antibodies transferred to the newborn through the placenta) In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues.

DIF: Cognitive Level: Remember/Knowledge REF: p. 447

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The process in which antibody and complement proteins attach to the target cell and enhance the phagocyte’s ability to engulf the target cell is known as a. opsonization. b. phagocytosis. c. the lymphoreticular system. d. the portal circulation.

ANS: A

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Neutrophils are attracted to and migrate to areas of inflammation or bacterial invasion, where they ingest and kill invading microorganisms by phagocytosis. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocyte’s ability to engulf the target cell. When infectious organisms escape the local phagocytic responses, they may be engulfed and destroyed in a similar fashion by the tissue macrophages within the lymphoreticular organs. The portal circulation of the spleen and liver filters the majority of blood, where infectious organisms can be removed before infecting the tissues.

DIF: Cognitive Level: Remember/Knowledge REF: p. 448

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

12. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. These responses a. are mutually exclusive. b. are nonspecific immune responses. c. are producers of antigens. d. work together to provide immunity.

ANS: D

Specificity refers to the finding that an immune response stimulates cells to develop immunity for a specific antigen. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. They are not mutually exclusive but act together to provide immunity. They do not produce antigens; they produce antibodies.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 448

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

13. Cellular immunity is mediated by a. B lymphocytes. b. T lymphocytes. c. immunoglobulins. d. suppressor B cells.

ANS: B

Cellular immunity is mediated by the T lymphocyte. Humoral immunity is mediated by B lymphocytes and involves the formation of antibodies (immunoglobulins) in response to specific antigens that bind to their receptor sites. Suppressor T cells (not B cells) downgrade and suppress the humoral and cell-mediated responses.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 449

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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14. The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower-than-normal ratio may indicate acquired immunodeficiency syndrome (AIDS). This is because T4 cells a. enhance humoral immune response. b. suppress the humoral response. c. suppress the cell-mediated response. d. are a feature of an autoimmune disease.

ANS: A

Once contact is made with a specific antigen, the T lymphocyte differentiates into helper/inducer T cells, suppressor T cells, and cytotoxic killer cells. Although these T cells are microscopically identical, they can be distinguished by proteins present on the cell surface called cluster of differentiation (CD). Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses. The ratio of helper to suppressor T cells is normally 2:1, and an alteration in this ratio may cause disease. For example, a depressed ratio (a decrease of helper T cells in relation to suppressor T cells) is found in acquired immunodeficiency syndrome (AIDS), whereas a higher ratio (a decrease in suppressor T cells in relation to helper T cells) is a feature of an autoimmune disease.

DIF: Cognitive Level: Remember/Knowledge REF: p. 449

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

15. The nurse understands that immunosurveillance is a function of a. helper T lymphocytes. b. suppressor T lymphocytes. c. T4 lymphocytes. d. killer T lymphocytes.

ANS: D

Cytotoxic or killer T cells (CD8 marker) participate directly in the destruction of antigens by binding to and altering the intracellular environment, which ultimately destroys the cell. Killer cells also release cytotoxic substances into the antigen cell that cause cell lysis. Killer T cells additionally provide the body with immunosurveillance capabilities that monitor for abnormal cells or tissue. This mechanism is responsible for the rejection of transplanted tissue and the destruction of single malignant cells. Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses.

DIF: Cognitive Level: Remember/Knowledge REF: p. 449

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

16. With minor vessel injury, primary hemostasis is achieved a. after several minutes. b. with fibrin to solidify the platelet plug.

NURSINGTB.COM c. usually within seconds. d. as a permanent solution.

ANS: C

With minor vessel injury, primary hemostasis is temporarily achieved with platelet plugs, usually within seconds. During secondary hemostasis, the platelet plug is solidified with fibrin, an end product of the coagulation pathway, and requires several minutes to reach completion.

DIF: Cognitive Level: Remember/Knowledge REF: p. 450

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

17. In vivo, the primary activator of the coagulation cascade occurs via the a. intrinsic pathway. b. extrinsic pathway. c. common pathway. d. either intrinsic or extrinsic pathway.

ANS: B

The classic theory of coagulation is viewed as occurring through two distinct pathways, intrinsic and extrinsic, which share a common “final” pathway, formation of insoluble fibrin. It is now known that the classic cascade theory of coagulation illustrates what occurs in vitro. In vivo, the primary activator of the coagulation cascade occurs via the extrinsic pathway. The intrinsic pathway serves to amplify the coagulation cascade.

DIF: Cognitive Level: Remember/Knowledge REF: p. 450

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

18. Common to both the intrinsic and the extrinsic pathway is a. factor XII. b. factor VII. c. factor X. d. subendothelial collagen.

ANS: C

When blood is exposed to subendothelial collagen or is “injured,” factor XII is activated, which initiates coagulation via the intrinsic pathway. In the extrinsic pathway, tissue injury precipitates release of a substance known as tissue factor, which activates factor VII. Factor VII is key in initiating blood coagulation, and the two pathways intersect at the activation of factor X. Both coagulation pathways illustrate a final common pathway of clot formation, retraction, and fibrinolysis.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 450

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

NURSINGTB.COM

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

19. The nurse is caring for a patient with cirrhosis of the liver. The nurse notes fresh blood starting to ooze from the patient’s rectum and intravenous site. The nurse contacts the provider expecting a prescription for a. an infusion of protein S factor. b. blood work to evaluate protein C level. c. a laboratory test to determine factor X level. d. vitamin K injections.

ANS: D

The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, and protein C and protein S (anticoagulation factors). Thus, liver disease and vitamin K deficiency are commonly associated with impaired hemostasis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 450

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

20. A patient with a history of pulmonary embolism is being worked up for a potential coagulopathy that increases the risk for clotting. The nurse understands that the provider may request a test for a. factor VII deficiency. b. factor X deficiency. c. protein C deficiency. d. factor IX deficiency.

ANS: C

The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, and X, necessary for clotting to occur and for anticoagulation factors protein C and protein S. A deficiency of anticoagulation factors could lead to increased clot formation and problems such as stroke and pulmonary emboli. A deficiency of protein C can be seen in factor V Leiden, which increases the risk of thromboembolic events.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 450 Genetics Box

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Hemoglobin b. White blood cell count c. Vitamin K d. Fibrin split products

21. The nurse understands that when clots break down in a patient with a hematological disorder, which value will increase?

ANS: D

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When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation but are seen in some hematological disorders as well as with thrombolytic therapy. Vitamin K is necessary for synthesis of factors II, VII, IX, and X, which are needed for clotting to occur. Hemoglobin may decrease if the patient is bleeding, and WBCs are not relevant to this scenario.

DIF: Cognitive Level: Remember/Knowledge REF: p. 451

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

22. The patient is being seen for complaints of general malaise, fatigue, and shortness of breath since having a cold 6 weeks earlier. The nurse should expect the provider to request a a. lymph node biopsy. b. differential blood count only. c. complete blood count (CBC) with differential. d. bone marrow biopsy.

ANS: C

The first screening diagnostic tests performed to detect hematological or immunological dysfunction are a complete blood count (CBC) with differential and a coagulation profile. The CBC evaluates the cellular components of blood. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC count and differential, platelet count, and cell morphologies. The most invasive microscopic examinations of the bone marrow or lymph nodes are reserved for circumstances when laboratory tests are inconclusive or when an abnormality in cellular maturation is suspected (e.g., aplastic anemia, leukemia, or lymphoma). A differential laboratory test is not done without the CBC first. A bone marrow biopsy is unwarranted; it would be performed only if preliminary studies indicated a hematological problem.

DIF: Cognitive Level: Understand/Comprehension REF: p. 452

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

23. A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues, is known as a. polycythemia. b. anemia. c. iron deficiency. d. an increase in hemoglobin.

ANS: B

The term anemia refers to a reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease). Iron-deficiency anemia is the most common type of anemia.

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DIF: Cognitive Level: Remember/Knowledge REF: Table 17-1

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

24. The patient is admitted with reports of chronic fatigue and shortness of breath. The nurse notices that the patient is tachycardic and has multiple bruises and petechiae on the body and arms. The patient also complains of frequent nosebleeds. The nurse should evaluate the patient’s ___________________ a. complete blood count. b. hemoglobin and hematocrit. c. electrolyte values. d. blood culture results.

ANS: A

In addition to the general symptoms of anemia, unique disorders have their own classic clinical features. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. The CBC with differential, which includes a platelet count, would allow for evaluation of all aspects of aplastic anemia. Hemoglobin and hematocrit help to assess for blood loss, but assessment of cause (e.g., low platelets) is more important. Electrolyte values and blood culture results are not relevant to this scenario

DIF: Cognitive Level: Analyze/Analysis REF: p. 451

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

25. The nurse is assessing a patient being admitted with fatigue and shortness of breath as well as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an enlarged liver. The nurse suspects that the patient has a. aplastic anemia. b. hemolytic anemia. c. sickle cell anemia. d. anemia due to acute blood loss.

ANS: B

Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis).

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DIF: Cognitive Level: Understand/Comprehension

REF: p. 460 | Table 17-8

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

26. The patient is complaining of severe joint pain, as well as fatigue and shortness of breath. The nurse notices that the patient’s joints are swollen and the legs are edematous. The nurse realizes that these are symptoms of a. anemia reflective of low volume. b. aplastic anemia. c. hemolytic anemia. d. sickle cell anemia.

ANS: D

Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. In crisis, the sickle cell patient often has decreased urine output, peripheral edema, and signs of uremia because renal tissue perfusion is impaired as a result of sluggish blood flow. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis). The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products.

DIF: Cognitive Level: Understand/Comprehension REF: Table 17-8

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

27. The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for a. an elevated bilirubin level. b. a low reticulocyte count. c. sickled cells.

NURSINGTB.COM d. low white blood cell and platelet counts.

ANS: A

Laboratory findings in anemia include a decreased RBC count and decreased hemoglobin and hematocrit values. The reticulocyte count is usually increased, indicating a compensatory increased RBC production with release of immature cells. This patient’s jaundice is indicative of hemolytic anemia. Patients with hemolytic anemia also have an increased bilirubin level. In sickle cell disease, a stained blood smear reveals sickled cells. In aplastic anemia, the reticulocyte, platelet, RBC, and WBC counts are decreased because the marrow fails to produce any cells.

DIF: Cognitive Level: Understand/Comprehension REF: Table 17-8

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

28. Critical to caring for the immunocompromised patient is the understanding that a. the immunocompromised patient has normal white blood cell (WBC) physiology. b. the immunosuppression involves a single element or process. c. infection is the leading cause of death in these patients. d. immune incompetence is symptomatic even without pathogen exposure.

ANS: C

Infection is the leading cause of death in the immunocompromised patient. The immunocompromised patient is one with defined quantitative or qualitative defects in WBCs or immune physiology. The defect may be congenital or acquired, and may involve a single element or multiple processes. Regardless of the cause, the physiological outcome is immune incompetence, with lack of normal inflammatory, phagocytic, antibody, or cytokine responses. Immune incompetence is often asymptomatic until pathogenic organisms invade the body and create infection.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 461 | Table 17-9

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

29. The nurse is evaluating the patient’s laboratory values and notes an IgG level of 240 mg/dL. The nurse realizes that this patient is a candidate for a. no change in therapy because the level is normal. b. an immunoglobulin infusion. c. gene replacement therapy. d. increased doses of immunosuppressive medications.

NURSINGTB.COM

ANS: B

Medical therapy is directed at reversing the cause of the immune dysfunction and preventing infectious complications. In primary immunodeficiencies, B-cell and T-cell defects are treated with specific replacement therapy or bone marrow transplantation. IgG blood levels of less than 300 mg/dL warrant immunoglobulin infusion. Gene replacement therapy may soon be a realistic curative treatment option for some disorders. In secondary immunodeficiencies, the underlying causative condition is treated. For example, malnutrition is corrected, or doses of immunosuppressive medications are adjusted. For this patient, immunosuppressive medications should be discontinued or doses lowered.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 461 | Table 17-9

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

30. The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient is immunosuppressed. The nurse should a. place the patient in a single room with a HEPA filtration system. b. tell staff that hand washing is not recommended when working with this patient. c. start as many intravenous lines as possible to provide potential antibiotics. d. avoid the use of antimicrobial soaps when bathing and providing perineal care.

ANS: A

Nursing interventions focus on protecting the patient from infection. Research studies support the use of high-efficiency particulate air (HEPA) filtration and laminar airflow in single-patient rooms for prevention of infection with airborne microorganisms. Nurses should diligently ensure adequate hygiene measures that include general bathing with antimicrobial soaps, oral care, and perineal care. Hand washing is paramount for staff, patients, and visitors. Nursing staff members play an important role in limiting breaks in skin integrity and ensuring sterile technique when procedures are unavoidable.

DIF: Cognitive Level: Apply/Application REF: p. 463

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

31. The nurse notes that the patient’s neutrophil count is less than 500 cells/microliter. The nurse realizes that this patient is a. is at low risk for infection. b. is at mild risk for infection. c. is at moderate risk for infection. d. is at severe risk for infection.

ANS: D

Neutropenia is defined as an absolute neutrophil count of less than 1500 cells/microliter of blood. Neutropenia may occur as a result of inadequate production or excess destruction of neutrophils. Patients with low neutrophil counts are predisposed to infections because of the body’s reduced phagocytic ability. Neutropenia is classified based on the patient’s predicted risk for infection: mild (1000-1500 cells/microliter), moderate (500-1000 cells/microliter), and severe (<500 cells/microliter).

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DIF: Cognitive Level: Analyze/Analysis REF: p. 465

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

32. The patient is admitted with neutropenia. The nurse should assess the patient frequently for a. signs of systemic infection. b. a drop in temperature from its normal set point. c. the absence of chills. d. bradycardia.

ANS: A

There are no specific signs or symptoms of a low neutrophil count. Every body system is examined for physical findings of infection. Typical signs may not be evident. Pain such as sore throat or urethral discomfort may be indicative of an infected site. Areas of heavy bacterial colonization (e.g., oral mucosa, perineal area, and venipuncture and catheter sites) have the highest risk of infection; however, the most common clinical infections are sepsis and pneumonia. Additional signs or symptoms of systemic infection include a rise in temperature from its normal set point, chills, and accompanying tachycardia.

DIF: Cognitive Level: Apply/Application

REF: p. 465

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

33. The patient’s white blood cell (WBC) level is 4000 cells/microliter. The differential shows a neutrophil count of 65% and a band level of 5%. The absolute neutrophil count is a. 4000 cells/microliter. b. 3000 cells/microliter. c. 2800 cells/microliter. d. 2600 cells/microliter.

ANS: C

The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands (immature neutrophils).

WBC  (segs + bands)

NURSINGTB.COM

This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia.

DIF: Cognitive Level: Apply/Application

REF: p. 465

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

34. The patient has a total white blood cell (WBC) count of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. This patient a. is at low risk for infection. b. is at mild risk for infection. c. is at moderate risk for infection. d. is at severe risk for infection.

ANS: D

The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands (immature neutrophils).

WBC  (segs + bands)

600  (0.70 + 0.05)

600  0.75 = 450 cells/microliter

This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia. Neutropenia is classified based on the patient’s predicted risk for infection: mild (1000-1500 cells/microliter), moderate (500-1000 cells/microliter), and severe (<500 cells/microliter).

DIF: Cognitive Level: Analyze/Analysis REF: p. 464

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

35. Desired patient outcomes for immunocompromised patient related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of a. less than 500 cells/microliter. b. 500 to 1000 cells/microliter. c. 1000 to 1500 cells/microliter.

NURSINGTB.COM d. 1500 cells/microliter or higher.

ANS: D

Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of 1500 cells/microliter or higher.

DIF: Cognitive Level: Understand/Comprehension REF: p. 464

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

36. The patient is diagnosed with lymphoma but has a normal white blood cell (WBC) count. The nurse understands that this patient a. has normal WBC function as the WBC is normal. b. will have increased bruising and bleeding. c. is at risk for infection. d. is at risk for an allergic reaction.

ANS: C

Malignant diseases involving WBCs are termed leukemia, lymphoma, and plasma cell neoplasm (multiple myeloma). Regardless of the specific neoplastic disorder, a deficiency of functional WBCs is a common problem. Despite normal serum cell counts, WBC activity is always impaired, and infection is the most common complication of all these disorders.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 465-466

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

37. The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is a. fever. b. night sweats. c. bone pain. d. lymph node enlargement.

ANS: C

Bone pain is common in multiple myeloma, whereas lymph node enlargement is more representative of lymphoma. Fever is particularly difficult to interpret because it may be a manifestation of the disease process or may accompany an infectious complication. General signs and symptoms such as fatigue, malaise, myalgias, activity intolerance, and night sweats are nonspecific indicators of immune disease.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 468 | Table 17-10

NURSINGTB.COM

OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

38. Cases of primary immunodeficiency are usually related to a. aging. b. nutritional deficiencies. c. malignancies. d. a single gene defect.

ANS: D

Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are examples of conditions that may be associated with acquired immunodeficiencies.

DIF: Cognitive Level: Understand/Comprehension REF: p. 469

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

39. The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned about acquired immune deficiency syndrome (AIDS). The patient’s blood work shows the presence of HIV antibodies. The nurse should explain that a. HIV symptoms will continue throughout the patient’s life. b. HIV is an acute disease with a short prognosis. c. HIV infection and AIDS are considered chronic diseases. d. very few people with HIV develop AIDS.

ANS: C

Seroconversion is manifested by the presence of HIV antibodies and usually occurs 2 to 4 weeks after the initial infection. Symptoms associated with seroconversion include flulike symptoms such as fever, sore throat, headache, malaise, and nausea and usually last 1 to 2 weeks. The earlier stages of HIV infection may last as long as 10 years and may produce few or no symptoms, although viral particles are actively replacing normal cells. AIDS is the final stage of HIV infection. It is estimated that 99% of untreated HIV-infected individuals will progress to AIDS. Treatment regimens with combined antiviral drug regimens are controlling the progression to AIDS. HIV infection and AIDS are now considered, for many infected individuals, chronic diseases.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 469

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Assessment

NURSINGTB.COM

MSC: NCLEX Client Needs Category: Physiological Integrity

40. When caring for a patient with HIV, the nurse should a. not focus on the mouth, as infections of the mouth are rare. b. assure the patient that infections are not a major problem at this point. c. inform the patient that the disease does not affect the respiratory system. d. monitor the patient’s medication regimen.

ANS: D

Nursing assessment includes evaluation of the neurological status, mouth, respiratory status, abdominal symptoms, and peripheral sensation. As with all immunosuppressed patients, those with HIV infection must be protected from infection. These patients provide additional clinical challenges because of their multisystemic, clinical complications. For unclear reasons, persons with HIV infection have a higher propensity for adverse drug reactions than other patient groups and require careful monitoring of all medication regimens.

DIF: Cognitive Level: Apply/Application

REF: p. 470

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

41. The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that a. all patients with bleeding disorders demonstrate active bleeding. b. many patients have bleeding that is not obvious. c. mucous membranes have a high threshold for bleeding. d. capillaries in mucous membranes lie deep in the membrane.

ANS: B

Although many patients with bleeding disorders demonstrate active bleeding from body orifices, mucous membranes, and open lesions or intravenous line sites, equal numbers of patients have less obvious bleeding. The most susceptible sites for bleeding are existing openings in the epithelial surfaces. Mucous membranes have a low threshold for bleeding because the capillaries lie close to the membrane surface, and minor injury may damage and expose vessels. Substantial blood loss can occur in any coagulopathy, resulting in hypovolemic shock.

DIF: Cognitive Level: Understand/Comprehension REF: p. 471

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

42. The nurse is caring for a patient diagnosed with anemia. This morning’s hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to a. continue monitoring the patient, as this hematocrit is normal. b. administer platelets to help control bleeding. c. give fresh frozen plasma to decrease prothrombin time. d. provide RBC transfusion because this level is below the normal threshold.

ANS: D

NURSINGTB.COM

Transfusion thresholds are established based on laboratory values and patient-specific variables. In general, a threshold for RBC transfusion is considered a hematocrit of 28% to 31%, based on the patient’s cardiovascular tolerance. If angina or orthostasis is present, a higher threshold may be maintained. The threshold for transfusing platelets is usually between 20,000 and 50,000/microliter. Cryoprecipitate is usually infused if the fibrinogen level is less than 100 mg/dL. Fresh frozen plasma is used to correct a prolonged prothrombin time and partial thromboplastin time or a specific factor deficiency.

DIF: Cognitive Level: Analyze/Analysis REF: p. 472

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

43. The patient is admitted with anemia caused by blood loss and thrombocytopenia and has a platelet count of 22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse should a. give the RBCs before the platelets. b. give the platelets before the RBCs. c. use local therapies to stop the bleeding. d. give the platelets and RBCs at the same time.

ANS: B

When the patient’s blood does not clot because of thrombocytopenia, administration of RBCs before platelets will result in RBC loss from disrupted vascular structures. Platelets should be given first. Local therapies to stop bleeding are used when systemic anticoagulation is necessary for treatment of another health condition (e.g., myocardial infarction, ischemic stroke, or pulmonary embolism). Local procoagulants act by direct tissue contact and initiation of a surface clot.

DIF: Cognitive Level: Apply/Application

REF: p. 472

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

44. The patient has a platelet count of 9,000/microliter. The nurse realizes that a. this is a normal platelet level. b. spontaneous bleeding may occur. c. the patient is at great risk for fatal hemorrhage. d. this level is considered slightly low.

ANS: C

A quantitative deficiency of platelets is termed thrombocytopenia. By definition, this is a platelet count of less than 150,000/microliter. A value of 30,000/microliter is considered critically low, and spontaneous bleeding may occur. Fatal hemorrhage is a great risk when the count is less than 10,000/microliter.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 474

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment

NURSINGTB.COM

MSC: NCLEX Client Needs Category: Physiological Integrity

45. The patient’s platelet count is 35,000/microliter. The provider prescribes administration of 10 units of single-donor platelets. After transfusion, the nurse can expect the patient’s platelet count to be a. between 85,000/microliter and 135,000/microliter. b. between 50,000/microliter and 75,000/microliter. c. greater than 150,000/microliter. d. between 150,000/microliter and 185,000/microliter.

ANS: A

Medical treatment of thrombocytopenia includes infusions of platelets. Patients who require multiple platelet transfusions should be evaluated for single-donor platelet products, which permit administration of 6 to 10 units of platelets with exposure to the antigens of only one person. For every unit of single-donor platelets, the platelet count should increase by 5000 to 10,000/microliter.

DIF: Cognitive Level: Apply/Application

REF: p. 474

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

46. The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis of DIC is made by evidence of a. a decrease in fibrin degradation products. b. an increased D-dimer level. c. thrombocytopenia. d. low fibrinogen levels.

ANS: B

Diagnosis of DIC is made based on recognition of pertinent risk factors, clinical symptoms, and the results of laboratory studies. Evidence of factor depletion in the form of thrombocytopenia and low fibrinogen levels is seen in the early phase; however, definitive diagnosis is made by evidence of excess fibrinolysis detectable by elevated fibrin degradation products, an increased D-dimer level, or a decreased antithrombin III level.

DIF: Cognitive Level: Remember/Knowledge REF: p. 467

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

Multiple Response

1. Numbers of white blood cells (WBCs) are increased in circumstances of (Select all that apply.)

a. inflammation.

b. allergy.

c. invasion by pathogenic organisms.

NURSINGTB.COM d. malnutrition. e. immune diseases.

ANS: A, B, C

WBCs play a key role in the defense against infectious organisms and foreign antigens. Numbers of WBCs are increased in circumstances of inflammation, tissue injury, allergy, or invasion with pathogenic organisms. Numbers of WBCs are diminished in conditions of malnutrition, advancing age, and immune diseases.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 444

OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. recognition of tissue as “self.” b. injury to tissues. c. infection. d. malignancy. e. unknown causes.

2. Autoimmunity can result from (Select all that apply.)

ANS: B, C, D, E

In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues. Autoimmunity can result from injury to tissues, infection, or malignancy, although in many cases the cause is not known.

DIF: Cognitive Level: Understand/Comprehension

REF: pp. 446-447

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. is necessary for tissue repair. b. inhibits the process called chemotaxis. c. is harmful when uncontrolled. d. is less efficient when complement proteins are present. e. occurs when mediators cause vasoconstriction.

3. Inflammation is initiated by cellular injury and (Select all that apply.)

ANS: A, C

Inflammation is initiated by cellular injury, is necessary for tissue repair, and is harmful when uncontrolled. When cellular injury occurs, a process called chemotaxis generates both a mediator and a neutrophil response. Mediator substances (histamine, serotonin, kinins, lysosomal enzymes, prostaglandin, platelet-activating factor, clotting factors, and complement proteins) are released at the site of injury. These mediators cause vasodilation, increase blood flow, induce capillary permeability, and promote chemotaxis and phagocytosis by neutrophils. Inflammatory symptoms such as redness, heat, pain, and swelling are sequelae of these responses. Complement proteins enhance the antibody activity, phagocytosis, and inflammation.

NURSINGTB.COM

DIF: Cognitive Level: Understand/Comprehension

REF: p. 448

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. opsonize bacteria. b. dilute toxins. c. deliver proteins. d. attach to the target cell. e. carry away toxins.

4. Exudate formation at the inflammatory site functions to (Select all that apply.)

ANS: B, C, E

Exudate formation at the inflammatory site has three functions: dilute toxins produced, deliver proteins and leukocytes to the site, and carry away toxins and debris. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocyte’s ability to engulf the target cell.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 448

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. hypoxic states. b. blood loss. c. impaired production of red blood cells. d. increased destruction of red blood cells. e. chronic obstructive pulmonary disease.

5. Causes of anemia include which of the following: (Select all that apply.)

ANS: B, C, D

Causes of anemia include (1) blood loss (acute or chronic), (2) impaired production of RBCs, (3) increased RBC destruction, or (4) a combination of these. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease).

DIF: Cognitive Level: Understand/Comprehension

REF: p. 456

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. chemotherapy. b. biotherapy. c. bone marrow transplantation. d. surgery. e. radiation.

6. When dealing with hematological malignancies, therapies that have significant management roles include which of the following: (Select all that apply.)

ANS: A, B, C, E

NURSINGTB.COM

Therapy commonly includes chemotherapy and biotherapy. Bone marrow transplantation is used in selected cases. Surgery may be performed to establish a pathological diagnosis by excisional or incisional biopsy but has no other significant role in the management of hematological malignancies. Radiation may be used to treat lymphoma when the disease is limited to single nodes or node groups.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 468 | Table 17-10

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. a single gene defect. b. AIDS. c. aging. d. nutritional deficiencies. e. immunosuppressive therapies.

7. Secondary immunodeficiency involves the loss of a previously functional immune defense system, which can be caused by (Select all that apply.)

ANS: B, C, D, E

In primary immunodeficiency, the dysfunction exists in the immune system. Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. AIDS is the most notable secondary immunodeficiency disorder caused by an infection. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are additional examples of conditions that may be associated with acquired immunodeficiencies.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 469

OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. aminoglycosides. b. antiplatelet agents. c. cephalosporins. d. vasoconstrictors. e. sulfonamides.

8. The nurse is caring for an elderly patient who is being admitted for anemia of unknown cause. The patient has been on multiple medications at home for various ailments. In assessing the patient’s medication list, the nurse notes medications that may alter hemostasis, including which of the following: (Select all that apply.)

ANS: A, B, C, E

Medications that may alter hemostasis include aminoglycosides, anticoagulants, antiplatelet agents, cephalosporins, histamine blockers, nitrates, sulfonamides, sympathomimetics, and vasodilators.

NURSINGTB.COM

DIF: Cognitive Level: Remember/Knowledge

REF: p. 471

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. assess fluids for occult blood. b. observe for oozing and bleeding and remove clots that form. c. limit invasive procedures. d. take temperatures rectally to increase accuracy. e. weigh dressings to assess blood loss.

9. In caring for the patient who has a coagulopathy, the nurse should (Select all that apply.)

ANS: A, C, E

Nursing interventions specific to the patient with a coagulopathy include the following: weigh dressings to assess blood loss, assess fluids for occult blood, observe for oozing and bleeding from skin and mucous membranes, and leave clots undisturbed. Precautions such as limiting invasive procedures, including indwelling urinary catheters or rectal temperature measurement, are also important.

DIF: Cognitive Level: Apply/Application

REF: p. 472

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. platelet infusions. b. administration of fresh frozen plasma. c. cryoprecipitate. d. packed RBCs. e. heparin.

10. Accepted treatments for disseminated intravascular coagulation (DIC) may require (Select all that apply.)

ANS: A, B, C, D

Administration of platelets is the highest priority for transfusion because they provide the clotting factors needed to establish an initial platelet plug from any bleeding site. Fresh frozen plasma is administered for fibrinogen replacement. It contains all clotting factors and antithrombin III; however, factor VIII is often inactivated by the freezing process, thus necessitating administration of concentrated factor VIII in the form of cryoprecipitate. Transfusions of packed RBCs are given to replace cells lost in hemorrhage. Although heparin’s antithrombin activity prevents further clotting, it may increase the risk of bleeding and may cause further problems. Its use is controversial when it is administered to patients with DIC.

DIF: Cognitive Level: Understand/Comprehension

REF: pp. 476-478

OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder. TOP: Nursing Process Step: Implementation

NURSINGTB.COM

MSC: NCLEX Client Needs Category: Physiological Integrity