A nurse is assisting with the care of a 7-year-old child.

Exhibits
The nurse is reviewing the data collection findings and diagnostic results. For each data collection finding, click to specify if the finding is consistent with leukemia, sickle cell anemia, or hemophilia. Each finding may support more than 1 disease process.

Reported pain

Bleeding

Temperature

Bruising

WBC count

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.

B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.

C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.

D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.

A. Pulmonary congestion B. Urticaria C. Vomiting D. Low back pain

Correct Answer is D

Explanation

A. Pulmonary congestion: Pulmonary congestion is associated more with fluid overload or transfusion-associated circulatory overload (TACO), not an acute hemolytic reaction.

B. Urticaria: Urticaria (hives) is more typical of a mild allergic reaction rather than an acute hemolytic reaction.

C. Vomiting: Although nausea and vomiting may occur in various transfusion reactions, it is not specific to an acute hemolytic reaction like low back pain is.

D. Low back pain: Low back pain, often around the kidneys, is a classic sign of an acute hemolytic reaction due to the breakdown of RBCs and the release of hemoglobin into the bloodstream, which can lead to renal damage. This reaction is a medical emergency requiring immediate intervention.

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Naxlex Comprehensive Predictor Exams

The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Correct Answer is D

Explanation

The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?

A nurse is reinforcing teaching with a client has a new diagnosis of aplastic anemia. When discussing the pathology of this disease, which of the following instructions should the nurse include in the teaching?

The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?

A nurse is collecting data from a client who has leukemia. Which of the following findings has the highest priority?

A nurse is collecting data from a client who has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings?

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?

The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?