A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be the best response by the nurse?

To detect evidence of infection such as fever and tachycardia

To detect evidence of dehydration that might have triggered a sickle cell crisis

To detect abnormal sounds suggestive of acute respiratory complications and/or heart failure

To detect motor strength and stroke-related signs and symptoms

Answer and Explanation

The Correct Answer is C

Reasoning:

Choice A reason: Detecting infection via fever and tachycardia is important in sickle cell anemia, but auscultation of lungs and heart is not primarily for these signs. Fever is assessed by temperature, and tachycardia by pulse, not stethoscope. Auscultation focuses on organ-specific complications like respiratory or cardiac issues, not systemic signs.

Choice B reason: Dehydration can trigger sickle cell crises, but auscultation of lungs and heart does not directly assess hydration status. Fluid status is evaluated through vital signs, skin turgor, or urine output, not heart or lung sounds, making this response less accurate for the purpose of auscultation.

Choice C reason: Auscultating lungs and heart in sickle cell anemia detects abnormal sounds indicating acute respiratory complications, like acute chest syndrome, or heart failure from chronic anemia or vaso-occlusion. Crackles, wheezes, or murmurs suggest these complications, making this the most accurate explanation for the child’s question.

Choice D reason: Motor strength and stroke-related signs are assessed through neurological exams, not lung or heart auscultation. While stroke is a risk in sickle cell anemia due to vaso-occlusion, auscultation targets cardiopulmonary complications, not motor or neurological deficits, making this response inappropriate.

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Correct Answer is C

Explanation

Reasoning:

Choice A reason: Teaching coughing and deep breathing techniques prevents respiratory infections but is not the primary intervention for immune thrombocytopenia (ITP). ITP involves autoimmune platelet destruction, increasing bleeding risk. While infection prevention is important, maintaining platelet counts through transfusion is more critical to prevent hemorrhage in ITP.

Choice B reason: Giving aspirin to control temperature is contraindicated in ITP, as aspirin inhibits platelet function, worsening bleeding risk in clients with low platelet counts. Fever management should use alternative antipyretics like acetaminophen, making aspirin administration inappropriate and potentially harmful in this condition.

Choice C reason: Administering platelets, as ordered, is a key intervention in immune thrombocytopenia when bleeding risk is high. ITP causes autoimmune destruction of platelets, leading to thrombocytopenia. Platelet transfusions restore counts, reducing the risk of spontaneous bleeding, such as intracranial or gastrointestinal hemorrhage, a critical concern in severe cases.

Choice D reason: Administering stool softeners prevents straining, which could cause bleeding in ITP due to low platelets. While useful, it is secondary to platelet transfusion, which directly addresses the primary issue of thrombocytopenia and bleeding risk, making it less urgent than restoring platelet counts.

A. An increased number of erythrocytes B. Erythrocytes that are microcytic and hypochromic C. Clustering of platelets with sickled red blood cells D. Erythrocytes that are macrocytic and hyperchromic

Correct Answer is B

Explanation

Reasoning:

Choice A reason: An increased number of erythrocytes is not indicative of iron-deficiency anemia, which is characterized by reduced red blood cell production due to low iron availability for hemoglobin synthesis. Increased erythrocytes suggest compensatory mechanisms or polycythemia, not the reduced erythropoiesis seen in iron deficiency.

Choice B reason: Microcytic and hypochromic erythrocytes are hallmarks of iron-deficiency anemia. Low iron impairs hemoglobin synthesis, leading to smaller (microcytic) and paler (hypochromic) red blood cells. This matches the client’s low hemoglobin and hematocrit, confirming iron deficiency as the cause of the anemia.

Choice C reason: Clustering of platelets with sickled red blood cells is specific to sickle cell anemia, not iron-deficiency anemia. Sickle cell disease involves hemoglobin S, causing cell deformation, not iron deficiency. Platelet clustering is unrelated to the microcytic, hypochromic cells of iron deficiency.

Choice D reason: Macrocytic and hyperchromic erythrocytes suggest megaloblastic anemia, typically from vitamin B12 or folate deficiency, not iron deficiency. Iron-deficiency anemia produces microcytic, hypochromic cells due to impaired hemoglobin synthesis, making macrocytic, hyperchromic cells inconsistent with the client’s laboratory findings.

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A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client diagnosed with immune thrombocytopenia. Which nursing intervention should be included in the plan of care?

Correct Answer is C

Explanation

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?

Correct Answer is B

Explanation

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