Nursing Assessment in Polycythemia Vera

Questions and Answers

How can the nurse best gauge the course of the client's disease in polycythemia vera?

Follow the trends of the client's hematocrit.

Which method is least effective for gauging the course of polycythemia vera?

Document the client's response to erythropoietin injections. (correct)

Document the color of the client's palms and face during each visit. (correct)

Follow the trends of the client's hematocrit.

Follow the client's erythrocyte sedimentation rate over time. (correct)

Which intervention by the nurse would decrease the risk for narcotic substance abuse in a client with sickle cell disease taking narcotic analgesics for pain control?

Teach the client to accept chronic pain as an inevitable aspect of the disease.

Encourage the client to rely on complementary and alternative therapies.

Limit the reporting of emergency department visits to the primary health care provider.

Encourage the client to seek care from a single provider for pain relief. (correct)

A client newly diagnosed with thrombocytopenia asks the nurse for an explanation of the condition. What should the nurse explain is the cause?

Decreased production of platelets. Signup and view all the answers

What treatment option may be considered for a client with immune hemolytic anemia who is not responding to conservative treatments?

Splenectomy Signup and view all the answers

What should the nurse include in health education for a client with iron deficiency anemia who has been prescribed iron supplements?

Iron will cause the stools to darken in color. Signup and view all the answers

What form of hematologic disorder is indicated by a client showing acute fatigue and a sore, smooth, beefy red tongue?

Megaloblastic anemia Signup and view all the answers

A client with acute kidney injury has decreased erythropoietin production. What will the nurse expect to find upon analysis of the client's complete blood count?

A decreased hemoglobin and hematocrit. Signup and view all the answers

With a low serum iron level and low ferritin level, what is the likely diagnosis for a client with symptoms of pica?

Iron deficiency anemia Signup and view all the answers

Which condition should a nurse suspect in a client with increased bilirubin concentration and reticulocyte count?

A hemolytic anemia Signup and view all the answers

For a client with pernicious anemia, which medication should the nurse prepare to administer?

Vitamin B12 Signup and view all the answers

What finding would be consistent with a client having a platelet level of 17,000/mm3?

Petechiae Signup and view all the answers

What medications should a nurse be alert for when admitting a client with immune thrombocytopenic purpura?

Aspirin-based drugs Signup and view all the answers

A client admitted with excessive bleeding shows prolonged prothrombin time. What is a plausible cause of the client's symptoms?

Hepatic dysfunction Signup and view all the answers

What is the expected prescription for a client with liver dysfunction due to bleeding esophageal varices?

Packed red blood cells (PRBCs) Signup and view all the answers

What nursing diagnosis is likely for a pediatric client with hemophilia?

Ineffective coping Signup and view all the answers

Which individual is most likely to have anemia?

An 81-year-old woman who has chronic heart failure Signup and view all the answers

What nursing diagnosis applies most likely to an adult client diagnosed with iron-deficiency anemia?

Fatigue related to decreased oxygen-carrying capacity Signup and view all the answers

Which assessment finding would signal complications of anemia in a client experiencing declines in hemoglobin levels?

Shortness of breath and peripheral edema Signup and view all the answers

What foods should a woman in her third trimester of pregnancy consume to increase her iron stores?

Beef liver accompanied by orange juice Signup and view all the answers

Which nursing diagnosis should the nurse prioritize in the client's plan of care?

Ineffective tissue perfusion related to thrombosis Signup and view all the answers

A client is being treated on the medical unit for a sickle cell crisis. Which action by the nurse would be the most appropriate?

Inform the health care provider that the client may have an infection. Signup and view all the answers

When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend?

Avoiding cold temperatures and ensuring sufficient hydration Signup and view all the answers

Which assessment question relates most directly to a client with glucose-6-phosphate dehydrogenase deficiency?

What medications have you taken recently? Signup and view all the answers

The nurse should assess for which factor in a client with a history of secondary polycythemia?

Evidence of lung disease Signup and view all the answers

What action should the nurse prioritize when caring for a client with an absolute neutrophil count (ANC) of 440/mm3 but no signs of infection?

Meticulous hand hygiene Signup and view all the answers

Which topic should the nurse prioritize when teaching a client diagnosed with a bleeding disorder?

Avoiding activities that carry a risk for injury Signup and view all the answers

When planning care for a new resident with a bleeding disorder, which action should the nurse include?

Implementing a plan for fall prevention Signup and view all the answers

A client with a recent diagnosis of ITP asks why platelets are not administered. How should the nurse respond?

Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body. Signup and view all the answers

Which component of a client's previous medication regimen may have contributed to the development of a qualitative platelet defect?

Aspirin Signup and view all the answers

What should the nurse's next action be for a client with hemophilia A who is bleeding?

Prepare for the administration of factor VIII. Signup and view all the answers

When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage for a client with hemophilia A, what principle should guide the nurse's interventions?

NSAIDs are contraindicated due to the risk for bleeding. Signup and view all the answers

When reviewing a client's medication administration record (MAR), what is the nurse's best action regarding a PRN antiemetic with both oral and subcutaneous options?

Contact the prescriber to have the subcutaneous option discontinued. Signup and view all the answers

What intervention should be performed in anticipation of a screening colonoscopy for a client with von Willebrand disease?

The client should be given necessary clotting factors before the procedure. Signup and view all the answers

In the case of a client who has overdosed on warfarin, which antidote should the nurse recognize as necessary?

Vitamin K Signup and view all the answers

Which ICU client most likely faces the highest risk of disseminated intravascular coagulation (DIC)?

A client who is being treated for septic shock Signup and view all the answers

Which practice should the nurse recommend to a client treated for polycythemia vera to prevent complications?

Avoiding tight and restrictive clothing on the legs Signup and view all the answers

Study Notes

Pain Management in Sickle Cell Disease

Encourage reliance on a single primary provider for consistent pain management and care coordination.
Avoid exclusive reliance on complementary therapies, as they may not sufficiently address pain.

Thrombocytopenia Insights

Characterization of thrombocytopenia primarily involves decreased production of platelets.
Possible causes include increased destruction or consumption of platelets, not typically immune issues.

Treatment of Immune Hemolytic Anemia

A splenectomy may be necessary if conservative treatments fail for immune hemolytic anemia.
Vitamin K is not effective for treating anemia; it targets vitamin K deficiency only.

Education on Iron Deficiency Anemia

Inform clients that iron supplements can cause darkening of stools.
Advise taking iron on an empty stomach and increasing vitamin C intake to enhance absorption.

Indicators of Megaloblastic Anemia

A smooth, beefy red tongue coupled with fatigue indicates potential megaloblastic anemia.

Acute Kidney Injury and Erythropoiesis

Anticipate decreased hemoglobin and hematocrit levels due to diminished erythropoietin production.

Symptoms of pica and low serum ferritin suggest diagnosis of iron deficiency anemia.

Identifying Hemolytic Anemia

Increased bilirubin levels and elevated reticulocyte counts are indicators of hemolytic anemia.

Pernicious Anemia Management

Vitamin B12 administration is critical for treating pernicious anemia.

Symptoms Associated with Low Platelet Count

Petechiae may appear when platelet counts fall below 20,000/mm3.

Medications Affecting Platelet Function

Monitor for the use of NSAIDs, aspirin, and sulfa-containing medications during assessments for immune thrombocytopenic purpura.

Causes of Excessive Bleeding with Prolonged PT

Prolonged prothrombin time without vitamin K deficiency points to possible hepatic dysfunction.

Treatment for Liver Dysfunction Complications

Packed red blood cells (PRBCs) are necessary for managing significant bleeding in clients with liver disease.

Coping with Hemophilia

Children with hemophilia may struggle with ineffective coping due to the chronic nature and inherited implications of the disorder.

High-Risk Groups for Anemia

Older adults, especially those with chronic heart conditions, face elevated risks for anemia.

Nursing Diagnosis for Anemia

Fatigue is the most common symptom associated with anemia, typically linked to decreased oxygen-carrying capacity.

Complications Linked to Long-Term Anemia

Monitor for shortness of breath and peripheral edema as potential complications indicative of heart failure.

Nutrition for Iron-Deficient Pregnant Women

Recommend iron-rich foods like beef liver paired with orange juice for improved iron absorption.

Prioritizing Nursing Diagnoses in Sickle Cell Crisis

Focus on ineffective tissue perfusion related to thrombosis during acute vaso-occlusive crises.

Infection Monitoring in Sickle Cell Patients

Early signs such as fever and lung auscultation findings necessitate immediate communication with the healthcare provider to investigate potential infections.### General Guidelines for Management
Avoiding Cold Temperatures: Helps to reduce the occurrence and severity of certain medical crises.
Hydration: Essential for managing health and preventing complications.

Glucose-6-Phosphate Dehydrogenase Deficiency

Primary Trigger: Recent medications can precipitate exacerbations of the deficiency.
Common Symptoms: Pallor, jaundice, and malaise.

Secondary Polycythemia

Key Assessment: Evidence of lung disease may indicate causes of secondary polycythemia due to reduced oxygenation.
Blood Donation: Not a contributing factor to secondary polycythemia.

Neutropenia Care

Hand Hygiene: Critical for preventing infections in clients with low absolute neutrophil counts.
Antibiotics and Nutrition: Less relevant for immediate care compared to strict hygiene practices.

Bleeding Disorders Education

Activity Limitations: Clients should avoid high-risk activities that could cause injury.
Focus on Immunization: Ensures safety but must consider bleeding risks associated with injections.

Safety in Long-Term Care Settings

Fall Prevention Plans: Important for residents with bleeding disorders to mitigate injury risk.

Immune Thrombocytopenic Purpura (ITP) Testing

Viral Causes: Hepatitis and HIV screening recommended due to their potential role in ITP.

Platelet Transfusion in ITP

Ineffectiveness: Platelet transfusions are typically avoided because the body rapidly destroys the transfused platelets.

Qualitative Platelet Defects

Aspirin Use: Known to induce platelet dysfunction, increasing bleeding risk.

Management of Hemophilia A

Factor VIII Administration: Prompt administration is crucial after injuries to manage bleeding effectively.

Pain Management in Hemophilia

NSAIDs: Contraindicated due to the risk of exacerbating bleeding; opioids are a safer option.

Medication Administration Considerations

Avoid Subcutaneous Injections: Necessary in clients with hemophilia to prevent bleeding complications.

von Willebrand Disease (vWD) Intervention

Clotting Factors: Essential to administer prior to invasive procedures to avoid bleeding.

Warfarin Overdose

Antidote: Vitamin K is the specific antidote for managing warfarin toxicity.

Disseminated Intravascular Coagulation (DIC) Risk

Septic Shock: Recognized as a high-risk condition for developing DIC, necessitating vigilant monitoring.

Polycythemia Vera Management

Avoid Tight Clothing: Reduces the risk of deep vein thrombosis due to increased blood viscosity.

Monitoring Course of Polycythemia Vera

Hematocrit Trends: Best measures disease progression; should remain below 45% to manage condition effectively.

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Description

This quiz focuses on the best methods for nurses to gauge the course of a client's disease in polycythemia vera. It also examines which assessment method is the least effective for monitoring this condition. Test your understanding of nursing practices related to this hematologic disorder.