ch62.doc

[Osborn] chapter 62

Learning Outcomes [Number and Title ]Learning Outcome 1 Explain how the hematologic system functions in an adult.Learning Outcome 2 Describe the types, characteristics, and functions of blood cells.Learning Outcome 3 Explain how the process of coagulation works in the event of

an injury.Learning Outcome 4 Describe appropriate nursing assessment/responsibilities

related to the hematologic system in the adult patient.Learning Outcome 5 Describe laboratory tests used to evaluate the hematologic

system.Learning Outcome 6 Distinguish between normal and abnormal test results for the

hematologic system.Learning Outcome 7 Discuss the meaning of “shift to the left.”

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. Identify the key items that define how the hematologic system functions.

Select all that apply.

1. The main component of the system is blood.2. Blood is a type of connective tissue.3. The hematologic system is a transport system that functions to provide nutrients

to the body.4. The hematologic system is a transport system that functions to remove toxins

from the body.5. The lymphatic and the reticuloendothelial/mononuclear phagocyte systems

contribute to the functions of the hematologic system.

Correct Answer:1. The main component of the system is blood.2. Blood is a type of connective tissue.3. The hematologic system is a transport system that functions to provide nutrients

to the body.4. The hematologic system is a transport system that functions to remove toxins

from the body.5. The lymphatic and the reticuloendothelial/mononuclear phagocyte systems

contribute to the functions of the hematologic system.

Rationale: The main component of the system is blood. Blood, which is composed of a variety of cells and supportive fluids, is an obvious component of the hematologic system. Blood is a type of connective tissue. Blood is identified as a type of connective tissue that runs throughout the body. The hematologic system is a transport system that functions to provide nutrients to the body. It provides a transport system that delivers nutrition, oxygen, and secretory products throughout the body. The hematologic system is a transport system that functions to remove toxins from the body. Blood transports wastes to the kidneys and liver for disposal. The lymphatic and the reticuloendothelial/mononuclear phagocyte systems contribute to the functions of the hematologic system. The lymphatic system, the spleen, the liver and the reticuloendothelial/mononuclear phagocyte system contribute to the overall function of the hematological system. Second, the immunologic products of the hematologic system are critical to the defense of the body.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


2. As a client ages, what changes are expected in the hematologic system?


1. The amount of red marrow and the number of stem cells decrease with aging.2. As stem cells decrease in number, they are gradually replaced by nonfunctional fat

cells.3. Hemoglobin levels tend to decrease after middle age, more so in men than women.4. There may be some T-cell function loss that may account for a poor response to

immunizations.5. Laboratory parameters change dramatically.

Correct Answer: 1. The amount of red marrow and the number of stem cells decrease with aging.2. As stem cells decrease in number, they are gradually replaced by nonfunctional

fat cells.3. Hemoglobin levels tend to decrease after middle age, more so in men than

women.4. There may be some T-cell function loss that may account for a poor response to

immunizations.

Rationale: The amount of red marrow and the number of stem cells decrease with aging. The amount of red marrow and the number of stem cells decrease with aging, but the marrow is not completely depleted, even in very old adults. As stem cells decrease in number, they are gradually replaced by nonfunctional fat cells. The remaining stem cells retain their functional capacity to divide, but as they decrease in number, they are gradually replaced by nonfunctional fat cells. Hemoglobin levels tend to decrease after middle age, more so in men than women. It is recognized that hemoglobin levels tend to decrease after middle age, more so in men than in women. There may be some T-cell function loss that may account for a poor response to immunizations. It has been suggested that there may be some T-cell function loss and that this may account for a poor response to immunizations. Laboratory parameters change dramatically. Laboratory parameters as they relate to the hematologic system of aging clients usually are not much different than those of a younger patient.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


3. When assessing a client for hematologic system status, the nurse should consider the following:


1. Family history2. Presenting symptoms3. Chief complaint4. Prior episodes with bleeding 5. Physical examination findings

Correct Answer: 1. Family history2. Presenting symptoms3. Chief complaint4. Prior episodes with bleeding 5. Physical examination findings

Rationale: Family history. Family history will assist the nurse in identifying potential susceptibilities to hematologic disorders. Presenting symptoms. Assessment of presenting symptoms will help pinpoint the source of problem. Chief complaint. Tells the nurse in the client’s own words and perceptions what is wrong. Prior episodes with bleeding. Past history provides insight into current problem. Physical examination findings. Physical examination may the pinpoint source of problem.

Cognitive level: ApplicationNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


4. What phrases best describe the characteristics of red blood cells?


1. Carry oxygen to tissues2. Maintain the chemical integrity of hemoglobin3. Assume a flexible disk shape that allows for optimal filling and transport to

body tissues4. Are terminally differentiated5. Have a life span of approximately 90 days

Correct Answer: 1. Carry oxygen to tissues2. Maintain the chemical integrity of hemoglobin3. Assume a flexible disk shape that allows for optimal filling and transport to

body tissues4. Are terminally differentiated

Rationale: Carry oxygen to tissues. This is a primary function of blood as a transport system. Maintain the chemical integrity of hemoglobin. The function of the red blood cells is to become filled with hemoglobin, maintain the integrity of hemoglobin, and distribute it to the body’s tissues. Assume a flexible disk shape that allows for optimal filling and transport to body tissues. The shape facilitates filling and transport of nutrients. Are terminally differentiated. Red blood cells can never divide. Have a life span of approximately 90 days. Actual life span is approximately 120 days.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 2


5. A client is admitted to the unit with a high count of lymphocytes. In reviewing the laboratory findings, the nurse will expect to find the following in addition to the high lymphocyte count:

Select all that apply.1. A presence of T cells.2. A presence of B cells.3. A presence of natural killer cells (NK cells).4. A presence of basophils.5. A presence of thrombocytes.

Correct Answer: 1. A presence of T cells.2. A presence of B cells.3. A presence of natural killer cells (NK cells).

Rationale: A presence of T cells. Approximately 60% to 70% of blood lymphocytes are T cells. A presence of B cells. Approximately 10% of blood lymphocytes are B cells. A presence of natural killer cells (NK cells). Natural killer cells (NK cells) are a type of lymphocytes that are functionally distinct from T and B cells. A presence of basophils. Basophils are a different type of white blood cell than lymphocytes. A presence of thrombocytes. Thrombocytes are a different type of cell that prevents blood from clotting.



6. A client with a family history of anemia is admitted to the unit. What type of blood cell would be characteristic of an inherited type of anemia?

1. Sickle cell 2. Lymphocyte3. Eosinophil4. Reticulocyte

Correct Answer: Sickle cell

Rationale: The sickle cell is an abnormal cell, shaped like a sickle, and is unique to sickle cell anemia, which may be inherited. Lymphocytes, platelets, and reticulocytes are normal cells present in blood.



7. In the formation of platelets, the megakaryocyte:

1. Breaks into pieces called platelets.2. Is a part of the formation of any cell type.3. Is necessary for RBC formation.4. Does not release platelets.

Correct Answer: Breaks into pieces called platelets.

Rationale: Megakaryocytes do break into pieces called platelets as part of the stem-cell-to-thrombocyte formation process. The stem cell is the precursor cell of all blood components (red blood cells, white blood cells, and platelets.) Megakaryocytes are not responsible for RBC formation.



8. Which of the following explains the difference between primary hemostasis and secondary hemostasis?


1. Primary hemostasis is characterized by vascular contraction.2. Primary hemostasis is characterized by platelet adhesion.3. Primary hemostasis is the stage in which a soft aggregate plug is formed.4. Secondary hemostasis is responsible for stabilizing the soft clot and maintaining

vasoconstriction.5. The coagulation cascade is activated during primary hemostasis.

Correct Answer:1. Primary hemostasis is characterized by vascular contraction.2. Primary hemostasis is characterized by platelet adhesion.3. Primary hemostasis is the stage in which a soft aggregate plug is formed.4. Secondary hemostasis is responsible for stabilizing the soft clot and maintaining

vasoconstriction.

Rationale: Primary hemostasis is characterized by vascular contraction. Primary hemostasis is characterized by vascular contraction, platelet adhesion, and formation of a soft aggregate plug. Primary hemostasis is characterized by platelet adhesion Primary hemostasis is characterized by vascular contraction, platelet adhesion, and formation of a soft aggregate plug. Primary hemostasis is the stage in which a soft aggregate plug is formed. Primary hemostasis is characterized by vascular contraction, platelet adhesion, and formation of a soft aggregate plug. Secondary hemostasis is responsible for stabilizing the soft clot and maintaining vasoconstriction. The clot is stabilized during the secondary phase and is initiated when the coagulation cascade is activated at the time of injury. The coagulation cascade is activated during primary hemostasis. The coagulation cascade is activated during secondary hemostasis.



9. Platelets aggregate in response to extrinsic factors that can be described as:

1. Trauma.2. Bacteria.3. Antibody−antigen reaction.4. WBCs.

Correct Answer: Trauma.

Rationale: A blood vessel must incur an injury in order for hemostasis to be initiated. Extrinsic factors refer to those outside of the blood vessel, such as an injury.Bacteria, antibody−antigen reactions, and white blood cells would all represent circulating proteins characteristic of intrinsic factors.



10. Physical examination related to the hematologic system of the adult client should include inspection of the:


1. Skin.2. Head and neck.3. Chest.4. Abdomen.5. Feet and legs.

Correct Answer:1. Skin.2. Head and neck.3. Chest.4. Abdomen.

Rationale: Skin. Changes in skin color often indicate erythrocyte disorders such as anemia. Head and neck. The structures of the head, particularly the eyes and mouth, provide useful evidence in the evaluation of the patient. The neck should be inspected for signs of lymph node enlargement or tenderness. Chest. Structures in the chest, heart, and lymph nodes yield clues to hematologic system disorders; for example, tachycardia is a response to both infection and anemia. Abdomen. Abdominal tenderness is a general complaint that might be indicative of splenomegaly or hepatomegaly, both indicators of increased blood destruction. Feet and legs. Feet and legs do not provide any specific clues to hematologic problems.

Cognitive level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 4


11. Identify the major way that alcohol consumption can affect the hematologic system.

1. Nutritional deficiencies2. Alteration in the clotting mechanism3. Acceleration of ethrocyte formation4. Acceleration of phagocytosis

Correct Answer: Nutritional deficiencies

Rationale: Excessive alcohol use results in vitamin deficiencies and potentially GI damage that can suppress hematopoiesis. Alcohol does not affect the clotting mechanism, erythocyte formation, or phagocytosis.



12. When assessing an older adult for possible hematologic problems, the nurse should pay particular attention to:


1. History of bleeding problems.2. Presenting symptoms and chief complaint.3. Presence of risk factors.4. General physical appearance.5. Laboratory parameters.

Correct Answer:1. History of bleeding problems.2. Presenting symptoms and chief complaint.3. Presence of risk factors.4. General physical appearance.

Rationale: History of bleeding problems. This provides clues as to possible current problems. Presenting symptoms and chief complaint. These tell the nurse in the patient’s own words what is wrong and alert the nurse to potential foci of current problems, for example, RBCs or WBCs. Presence of risk factors. These make known an individual’s susceptibility to specific disorders. General physical appearance. This conveys an impression of health status. Laboratory parameters. There is usually not much difference in laboratory parameters of the aging client and younger clients.



13. Which of the following describes the difference between the hemoglobin and hematocrit values of a complete blood count?

1. Hemoglobin is the amount of functional, or iron-containing, protein of the red blood cell, whereas hematocrit represents the percentage of hemoglobin in a given volume of blood.

2. Hemoglobin represents the percentage of functional protein of the red blood cell, whereas hematocrit is an indicator of the amount of functional protein of the red blood cell.

3. Hemoglobin values vary between men and women, but hematocrit values do not vary between men and women.

4. Hemoglobin values tend to be higher for males, and hematocrit values tend to be higher in females.

Correct Answer: Hemoglobin is the amount of functional, or iron-containing, protein of the red blood cell, whereas hematocrit represents the percentage of hemoglobin in a given volume of blood.

Rationale: Hemoglobin is the iron-containing protein that bonds with oxygen, allowing the red blood cells to transport oxygen throughout the body. Normal values are higher for men than for women. Hematocrit, sometimes called paced cell volume, measures the portion of blood volume made up by red blood cells. Hematocrit values also tend to be higher in men than in women.



14. Normal values of coagulation studies include:


1. Prothrombin time (PT): 12 to 15 seconds.2. Thrombin time: 8 to 12 seconds.3. Fibrinogen: 200 to 400 mg/dL.4. Activated partial thromboplastin tme (aPTT): 60 seconds.5. Bleeding time: less than 1 minute.

Correct Answer:1. Prothrombin time (PT): 12 to 15 seconds.2. Thrombin time: 8 to 12 seconds.3. Fibrinogen: 200 to 400 mg/dL.

Rationale: Prothrombin time (PT): 12 to 15 seconds. This value is within the correct time parameters. Thrombin time: 8 to 12 seconds. This time is within the normal parameters. Fibrinogen: 200 to 400 mg/dL. This value is within the normal parameters. Activated partial thromboplastin time (aPTT): 60 seconds. This is too long; the normal value is 30 to 45 seconds. Bleeding time: less than 1 minute. This is too short of a time period; normal parameters are 1 to 6 minutes.



15. The differential blood count measures:

1. The percent of the five types of white blood cells in a sample of 100 white blood cells.

2. Inflammation, infection, and response to therapy.3. Volume of red blood cells in whole blood.4. Number of thrombocytes in whole blood.

Correct Answer: The percent of the five types of white blood cells in a sample of 100 white blood cells

Rationale: The differential count measures the amount of different types of white blood cells present in the blood sample—neutrophils, lymphocytes, monocytes, eosinophils, and basophils. Inflammation, infection, and response to therapy are measured by the total white blood cell count. A hematocrit count measures the volume of red blood cells in whole blood. The number of thrombocytes in whole blood is measured by a platelet count.



16. A decreased RBC count can be due to:

Select all that apply.1. Bleeding that results in an abnormal loss of erythrocytes.2. Abnormal destruction of erythrocytes.3. Lack of needed hormones and elements for production of erythrocytes.4. Bone marrow suppression.5. An excessive production of hormones needed for the production of erythrocytes.

Correct Answer:1. Bleeding that results in an abnormal loss of erythrocytes.2. Abnormal destruction of erythrocytes.3. Lack of needed hormones and elements for production of erythrocytes.4. Bone marrow suppression.

Rationale: Bleeding that results in an abnormal loss of erythrocytes. This causes a lowering of RBC count. Abnormal destruction of erythrocytes. This causes a lowering of RBC count. Lack of needed hormones and elements for production of erythrocytes. This causes a lowering of RBC count. Bone marrow suppression. This causes a lowering of RBC count. An excessive production of hormones needed for the production of erythrocytes. This would cause an increase in RBC count.



17. Identify which of the following disorders would result from a decrease in the number of cells.


1. Thrombocytopenia2. Leukopenia3. Polycemia4. Splenomegaly5. Myeloma

Correct Answer:1. Thrombocytopenia2. Leukopenia

Rationale: Thrombocytopenia. This is the presence of relatively few platelets in blood. Leukopenia. This is a decrease in the number of circulating white blood cells. Polycemia. This occurs when excess red blood cells are produced as a result of an abnormality of the bone marrow. Splenomegaly. This is an enlargement of the spleen. Myeloma. This is a form of bone cancer caused by a caused by overproduction of immune cells in bone marrow.



18. A client’s assessment data indicates a potential bleeding problem. What laboratory studies will be used to isolate the problem?


1. Platelet count2. Prothrombin time (PT)3. Bleeding time4. Activated partial thromboplastin time (aPTT)5. Fibrinogen split products

Correct Answer:1. Platelet count2. Prothrombin time (PT)3. Bleeding time4. Activated partial thromboplastin time (aPTT)

Rationale: Platelet count. The platelet count is a test that determines the number of platelets in the blood, and depicts clotting potential. Prothrombin time (PT). Prothrombin time depicts extrinsic coagulation factors. Bleeding time. Bleeding time reflects platelet interaction and capillary constriction. Activated partial thromboplastin time (aPTT). aPTT reflects intrinsic coagulation factors critical to the clotting cascade. Fibrinogen split products. This is useful in detection of DIC, which is triggered by an injury or event leading to persistent activation of the clotting cascade, not by a bleeding problem per se.



19. When a “shift to the left” occurs, the nurse should consider the possibility of the following disorders:


1. Undetected infection.2. Bone marrow disease.3. Immune system insufficiencies.4. Immunosuppressive therapies.5. Presence of foreign cells in the bone marrow.

Correct Answer:1. Undetected infection2. Bone marrow disease3. Immune system insufficiencies4. Immunosuppressive therapies

Rationale: Undetected infection. A “shift to the left” is a compensatory mechanism to combat infection. Bone marrow disease. A “shift to the left” may be indicative of bone marrow disease. Immune system insufficiencies. A “shift to the left” may be indicative of immune system insufficiencies caused by bone marrow disease. Immunosuppressive therapies. A “shift to the left” may occur as a result of immunosuppressive therapies such as chemotherapy. Presence of foreign cells in the bone marrow. A “shift to the left” is not indicative of the presence of foreign cells in the marrow.



20. Which laboratory value is indicative of a “shift to the left”?

1. Increase in total white blood cell count2. Increase in absolute neutrophils count (ANC)3. Increase in platelets4. Increase in erythrocytes

Correct Answer: Increase in total white blood cell count

Rationale: A “shift to the left” phenomenon represents an increase in the total white blood cell count. The bone marrow is stimulated to release a large number of relatively immature cells and juvenile cells as a compensatory mechanism to combat severe infection. An increase in absolute neutrophils, platelets, and erythrocytes is not indicative of a “shift to the left.”



20. The health care provider should be notified immediately if a client experiences a “shift to the left” in laboratory values because:

1. It is an indicator of risk for a severe infection.2. It is an indicator of a potential bleeding problem.3. It is an indicator of electrolyte imbalance.4. It is an indicator of disruption of hemostasis.

Correct Answer: It is an indicator of risk for a severe infection.

Rationale: During a “shift to the left,” the bone marrow is stimulated to release a large number of relatively immature cells and juvenile cells as a compensatory mechanism to combat severe infection. In an otherwise healthy individual, this may signal an early sign of an otherwise undetected infection, and the client may not have sufficient host defenses. A “shift to the left” does not pertain to potential bleeding problems, electrolyte imbalance, or hemostasis disruption.



ch62.doc

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