A patient is admitted to determine why red blood cells are being quickly destructed in the body. What finding should the nurse associate with this patient's health problem?
clotting
Cyanosis
Jaundice
Bleeding
The Correct Answer is C
A. Clotting is not directly related to the destruction of red blood cells.
B. Cyanosis refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation, which is not directly indicative of red blood cell destruction.
C. Jaundice is the yellowing of the skin and eyes caused by the buildup of bilirubin, a byproduct of the destruction of red blood cells, which is a common symptom of hemolytic anemia.
D. Bleeding is not a symptom associated with the destruction of red blood cells but rather a lack of clotting factors or platelets.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inadequate production of platelets results in an increased risk of bleeding, making the client vulnerable to injury. Therefore, the priority nursing diagnosis is "Risk for Injury related to increased bleeding tendency."
B. Decreased antibody production is not directly related to inadequate platelet production.
C. While decreased platelet production may contribute to hypovolemia in some cases, the primary concern is the risk of bleeding rather than decreased cardiac output.
D. Impaired gas exchange is not directly related to inadequate platelet production.
Correct Answer is B
Explanation
A. Presence of plethora is a common symptom of polycythemia vera and indicates increased blood volume but is not immediately life-threatening.
B. Calf swelling and pain could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate medical attention.
C. A platelet count of 450,000/microL is elevated but not as critical as the possibility of a DVT.
D. Hematocrit of 55% is high, which is expected in polycythemia vera, but it is not as immediately critical as the risk of thrombosis suggested by calf swelling and pain.
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