A nurse is assisting with the care of a 7-year-old child.
Reported pain
Bleeding
Temperature
Bruising
WBC count
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,C"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Reported pain
- Leukemia: Possible, as bone pain can occur due to marrow involvement.
- Sickle Cell Anemia: Yes, common due to vaso-occlusive crises.
- Hemophilia: No, hemophilia typically causes bleeding rather than pain from blood cell abnormalities.
Bleeding
- Leukemia: Yes, due to thrombocytopenia.
- Sickle Cell Anemia: No, bleeding is not typical in sickle cell crises.
- Hemophilia: Yes, hemophilia is a bleeding disorder due to a clotting factor deficiency.
Temperature
- Leukemia: Yes, fever can indicate infection due to immunosuppression.
- Sickle Cell Anemia: Yes, fever can be a sign of infection during crises.
- Hemophilia: No, hemophilia does not cause fever unless there is an infection.
Bruising
- Leukemia: Yes, thrombocytopenia can lead to easy bruising.
- Sickle Cell Anemia: No, bruising is not typical in sickle cell crises.
- Hemophilia: Yes, due to a clotting factor deficiency, easy bruising is common.
WBC count
- Leukemia: Yes, often elevated due to immature or abnormal white cells.
- Sickle Cell Anemia: No, WBC count is usually normal unless there is an infection.
- Hemophilia: No, WBC count is typically normal in hemophilia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.
B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.
C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.
D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.
Correct Answer is D
Explanation
A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.
B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.
C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.
D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.
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