The Child with a Hematological Alteration

MULTIPLE CHOICE

1. The nurse is assessing a client admitted with cyanotic heart disease. Which hematology laboratory result does the nurse expect to assess?

a.
Anemia
b.
Polycythemia
c.
Normal
d.
Decreased hemoglobin

ANS: B

Polycythemia can occur as a result of hypoxia, such as that experienced at high altitude or when oxygen is not sufficiently directed to the tissues, as in cyanotic heart disease. Anemia is a decrease in the number of RBCs, a reduction in their hemoglobin content, or a reduced volume of packed RBCs. Anemia results from one of two problems: either too rapid a loss of RBCs (by covert or overt bleeding or destruction) or too slow a production of RBCs. Anemias are categorized according to the size of the RBC (macrocytic, microcytic, normocytic) and the content of hemoglobin in the RBC (hypochromic, normochromic). The hematology laboratory result would not be normal because of the chronic hypoxia seen with cyanotic heart disease.

DIF: Cognitive Level: Analysis REF: p. 571

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

2. What is the best response to a parent who asks the nurse whether her 5-month-old infant can have cow’s milk?

a.
“You need to wait until she is 8 months old and eating solids well.”
b.
“Yes, if you think that she will eat enough meat to get the iron she needs.”
c.
“Infants younger than 12 months need iron-rich formula to get the iron they need.”
d.
“Try it and see how she tolerates it.”

ANS: C

Infants younger than 12 months need iron-fortified formula or breast milk. Infants who drink cow’s milk do not get adequate iron and are at risk for iron deficiency anemia. A 5-month-old infant cannot get adequate iron without drinking an iron-fortified formula or taking an iron supplement. The American Academy of Pediatrics recommends beginning solid foods at 4 to 6 months of age. Meats are typically introduced in late infancy. Counseling a parent to give a 5-month-old infant cow’s milk is inappropriate.

DIF: Cognitive Level: Application REF: p. 573

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

3. An assessment of a 7-month-old infant with a hemoglobin level of 6.5 mg/dL is likely to reveal which of the following?

a.
An infant who is lethargic, pale, and irritable
b.
An infant who is thin, energetic, and sleeps little
c.
An infant who is anorexic, vomiting, and has watery stools
d.
An infant who is flushed, fussy, and tired

ANS: A

Pallor, lethargy, irritability, and tachycardia are clinical manifestations of iron-deficiency anemia. Infants with iron-deficiency anemia are not typically thin and energetic but do tend to sleep a lot. Gastrointestinal symptoms are not clinical manifestations associated with iron-deficiency anemia. Although the infant with iron-deficiency anemia may be tired and fussy, pallor, rather than a flushed appearance, is characteristic of a low hemoglobin level.

DIF: Cognitive Level: Application REF: p. 573

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

4. Which suggestion is not appropriate for a 14-month-old child with iron-deficiency anemia?

a.
Decrease the infant’s daily milk intake to 24 ounces or less.
b.
Give oral iron supplements between meals with orange juice.
c.
Include apricots, dark-green leafy vegetables, and egg yolk in the infant’s diet.
d.
Allow the infant to drink the iron supplement from a small medicine cup.

ANS: D

Iron supplements should be administered through a straw or by a medicine dropper placed at the back of the mouth because iron temporarily stains the teeth. A daily milk intake in toddlers of less than 24 ounces will encourage the consumption of iron-rich solid foods. Because food interferes with the absorption of iron, iron supplements are taken between meals. Administering this medication with foods rich in vitamin C facilitates absorption of iron. Apricots, dark-green leafy vegetables, and egg yolks are rich sources of iron. Other iron-rich foods include liver, dried beans, Cream of Wheat, iron-fortified cereal, and prunes.

DIF: Cognitive Level: Application REF: p. 574

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

5. Which is true about the genetic transmission of sickle cell disease?

a.
Both parents must carry the sickle cell trait.
b.
Both parents must have sickle cell disease.
c.
One parent must have the sickle cell trait.
d.
Sickle cell disease has no known pattern of inheritance.

ANS: A

Sickle cell disease has an autosomal recessive transmission pattern, which means that both parents must be carriers of the sickle cell trait. The sickle cell trait, not the disease itself, must be present in the parents for the child to have the disease.

DIF: Cognitive Level: Application REF: p. 575

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

6. What are the nursing priorities for a child with sickle cell disease in vaso-occlusive crisis?

a.
Administration of antibiotics and nebulizer treatments
b.
Hydration and pain management
c.
Blood transfusions and an increased calorie diet
d.
School work and diversion

ANS: B

Hydration and pain management decrease the cells’ oxygen demands and prevent sickling. Antibiotics may be given prophylactically. Oxygen therapy rather than nebulizer treatments is used to prevent further sickling. Although blood transfusions and increased calories may be indicated, they are not primary considerations for a vaso-occlusive crisis. Schoolwork and diversion are not major considerations when the child is in a vaso-occlusive crisis.

DIF: Cognitive Level: Application REF: p. 579

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

7. A child with sickle cell disease is seen in the emergency department with increasing back and leg pain for the past 2 days. What is this child most likely experiencing?

a.
A vaso-occlusive crisis
b.
Acute splenic sequestration
c.
Erythroblastopenia
d.
Acute chest syndrome

ANS: A

A vaso-occlusive crisis is the most common type of crisis and is characterized by mild to severe pain. Pain can occur anywhere, but is typically manifested as bone or joint pain. Symptoms of acute splenic sequestration are associated with blood volume pooling, causing splenic enlargement and hypovolemic shock. Symptoms of pallor, lethargy, headache, and upper respiratory infection seen in erythroblastopenia result from decreased blood cell production by the bone marrow. Chest pain, fever, and cough are characteristic of acute chest syndrome.

DIF: Cognitive Level: Analysis REF: p. 577

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

8. What should the discharge plan for a school-age child with sickle cell disease include?

a.
Restricting the child’s participation in outside activities
b.
Administering aspirin for pain or fever
c.
Limiting the child’s interaction with peers
d.
Administering penicillin daily as ordered

ANS: D

Children with sickle cell disease are at a high risk for pneumococcal infections and should receive long-term penicillin therapy and preventive immunizations. Sickle cell disease does not prohibit the child from outdoor play. Active and passive exercises help promote circulation. Aspirin use should be avoided. Acetaminophen or ibuprofen should be administered for fever or pain. The child needs to interact with peers to meet his developmental needs.

DIF: Cognitive Level: Analysis REF: p. 580

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

9. How should the nurse respond when asked by the mother of a child with beta-thalassemia why the child is receiving deferoxamine?

a.
“To improve the anemia.”
b.
“To decrease hepatosplenomegaly.”
c.
“To prevent organ damage.”
d.
“To prepare your child for a bone marrow transplant.”

ANS: C

Multiple transfusions result in hemosiderosis. Deferoxamine is given to chelate iron and prevent organ damage and complications from repeated transfusions. Preparation for a bone marrow transplant would not include administration of deferoxamine.

DIF: Cognitive Level: Application REF: pp. 581-582

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

10. What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting from hemophilia?

a.
Immobilization and elevation of the affected joint
b.
Administration of aspirin for pain relief
c.
Assessment of the child’s response to hospitalization
d.
Assessment of the impact of hospitalization on the family system

ANS: A

Immobilization and elevation of the joint will prevent further injury until bleeding is resolved. Aspirin inhibits platelet function and is not recommended for the treatment of hemarthrosis. Assessment of a child’s response to hospitalization is relevant to all hospitalized children; however, in this situation, psychosocial concerns are secondary to physiological concerns. A priority nursing concern for this child is the management of hemarthrosis. Assessing the impact of hospitalization on the family system is relevant to all hospitalized children, but it is not the priority in this situation.

DIF: Cognitive Level: Application REF: p. 584

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

11. The mother of a child with hemophilia asks the nurse how long her child will need to be treated for hemophilia. What is the best response to this question?

a.
“Hemophilia is a life-long blood disorder.”
b.
“There is a 25% chance that your child will have spontaneous remission and treatment will no longer be necessary.”
c.
“Treatment is indicated until after your child has progressed through the toddler years.”
d.
“It is unlikely that your child will need to be treated for his hemophilia because your first child does not have the disease.”

ANS: A

Hemophilia is a life-long hereditary blood disorder with no cure. Prevention by avoiding activities that induce bleeding and by treatment is life long. The management of hemophilia is very individual and depends on the severity of the illness. Because hemophilia has an X chromosome-linked recessive inheritance, there is a risk with each pregnancy that a child will either have the disease or be a carrier.

DIF: Cognitive Level: Application REF: p. 583

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

12. What is an expected outcome for the child with von Willebrand’s disease?

a.
Prevention of injury
b.
Maintaining adequate hydration
c.
Compliance with chronic transfusion therapy
d.
Prevention of respiratory infections

ANS: A

Hemorrhage as a result of injury is the child’s greatest threat to life. Fluid volume status becomes a concern when hemorrhage has occurred. The treatment of von Willebrand’s disease is desmopressin acetate (DDAVP), which is administered intranasally or intravenously. Respiratory infections do not constitute a major threat to the child with von Willebrand’s disease.

DIF: Cognitive Level: Comprehension REF: p. 587

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

13. A child has a platelet count of 45,000/mm3 with petechiae and excessive bruising covering his body. The nurse is aware that these signs are clinical manifestations of:

a.
erythroblastopenia.
b.
von Willebrand’s disease.
c.
hemophilia.
d.
immune thrombocytopenia purpura (ITP).

ANS: D

Excessive bruising and petechiae, especially involving the mucous membranes and gums in a child who is otherwise healthy, are the clinical manifestations of ITP, resulting from decreased platelets. The etiology of ITP is unknown, but it is considered to be an autoimmune process. The clinical manifestations of erythroblastopenia are pallor, lethargy, headache, fainting, and a history of upper respiratory infection. The clinical manifestations of von Willebrand’s disease are bleeding from the gums or nose, prolonged bleeding from cuts, and excessive bleeding after surgery or trauma. Bleeding is the clinical manifestation of hemophilia and results from a deficiency of normal factor activity necessary to produce blood clotting.

DIF: Cognitive Level: Analysis REF: p. 587

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

14. What is the priority in the discharge plan for a child with immune thrombocytopenic purpura (ITP)?

a.
Teaching the parents to report excessive fatigue to the physician
b.
Monitoring the child’s hemoglobin level every 2 weeks
c.
Providing a diet that contains iron-rich foods
d.
Establishing a safe, age-appropriate home environment

ANS: D

Prevention of injury is a priority concern for a child with ITP. Excessive fatigue is not a significant problem for the child with ITP. ITP is associated with low platelet levels. Increasing the child’s intake of iron in the diet will not correct ITP.

DIF: Cognitive Level: Application REF: p. 588

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

15. The care plan for a child with disseminated intravascular coagulation (DIC) includes:

a.
hospitalization at the first sign of bleeding.
b.
teaching the child relaxation techniques for pain control.
c.
management in the intensive care unit.
d.
provision of adequate hydration to prevent complications.

ANS: C

The child with DIC is seriously ill and needs to be monitored in an intensive care unit. Relaxation techniques and pain control are not high priorities for the child with DIC. The child with DIC is seriously ill and needs to be monitored in an intensive care unit. Hydration is not the major concern for the child with DIC.

DIF: Cognitive Level: Comprehension REF: p. 590

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

16. What would be the nurse’s best response to a parent with questions about her child’s blood disorder?

a.
“That sounds pretty serious.”
b.
“What did the physician tell you?”
c.
“Blood diseases are transient, so there is no need to worry.”
d.
“Your child will be tired for awhile and then be back to her old self.”

ANS: B

Providing the parent with an opportunity to express what she was told by the physician allows the nurse to assess the parent’s understanding. Stating that the condition sounds serious may increase their anxiety. Minimizing the parent’s concern is inappropriate. The nurse needs to assess the parent’s knowledge before teaching about the disease.

DIF: Cognitive Level: Application REF: p. 573

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse is caring for a child with aplastic anemia. Which of the following nursing diagnoses would be appropriate? Select all that apply.

a.
Acute pain related to vaso-occlusion
b.
Risk for infection related to inadequate secondary defenses or immunosuppression
c.
Ineffective protection related to thrombocytopenia
d.
Ineffective tissue perfusion related to anemia

ANS: B, C, D

Risk for infection, ineffective protection, and ineffective tissue perfusion are appropriate nursing diagnoses for the nurse planning care for a child with aplastic anemia. Aplastic anemia is a condition in which the bone marrow ceases production of the cells it normally manufactures, resulting in pancytopenia. The child will have varying degrees of the disease depending on how low the values are for absolute neutrophil count (affecting the body’s response to infection), platelet count (putting the child at risk for bleeding), and absolute reticulocyte count (causing the child to have anemia). Acute pain related to vaso-occlusion is an appropriate nursing diagnosis for sickle cell anemia for the child in vaso-occlusive crisis, but it is not applicable to a child with aplastic anemia.

DIF: Cognitive Level: Application REF: p. 591

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

2. A nurse is caring for a neonate requiring phototherapy for a high bilirubin. Which interventions should the nurse implement? Select all that apply.

a.
Cover the neonate’s eyes with an opaque mask.
b.
Limit repositioning of the neonate.
c.
Dress the neonate in a T-shirt and diaper.
d.
Monitor the bilirubin level.
e.
Monitor temperature ever 2 to 4 hours.

ANS: A, D, E

During hospitalization, to maximize the effectiveness of phototherapy, the neonate should be completely undressed or wearing only a diaper. While phototherapy is in use, the neonate’s eyes are covered with an opaque mask that is usually secured in place with a headband or cloth adhesive. The neonate’s position is changed frequently to ensure maximal skin exposure to the light source. Monitoring the neonate’s bilirubin level is performed one to four times daily to assess the effectiveness of phototherapy. The nurse monitors the neonate’s temperature every 2 to 4 hours to ensure maintenance within normal limits. The additional heat generated by the phototherapy unit places the neonate at risk for hyperthermia. The lack of clothing on the neonate increases the possibility of heat loss through convection, conduction, radiation, and evaporation and may lead to hypothermia.

DIF: Cognitive Level: Application REF: p. 594

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

3. A nurse is teaching home care instructions to parents of a child with sickle cell disease. Which instructions should the nurse include? Select all that apply.

a.
Limit fluid intake.
b.
Administer aspirin for fever.
c.
Administer penicillin as ordered.
d.
Avoid cold and extreme heat.
e.
Provide for adequate rest periods.

ANS: C, D, E

Parents should be taught to avoid cold, which can increase sickling, and extreme heat, which can cause dehydration. Adequate rest periods should be provided. Penicillin should be administered daily as ordered. The use of aspirin should be avoided; acetaminophen or ibuprofen should be used as an alternative. Fluids should be encouraged and an increase in fluid intake is encouraged in hot weather or when there are other risks for dehydration.

DIF: Cognitive Level: Application REF: p. 578

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity