The patient, age 35, is admitted with aplastic anemia. He asks the nurse what aplastic anemia is. An accurate response would be that

the activity of the bone marrow is depressed.

red cells are absent as a result of chronic blood loss.

the bone marrow fails to produce lymphocytes.

the kidneys fail to produce red blood cells.

Answer and Explanation

The Correct Answer is A

A.   The activity of the bone marrow is depressed. Aplastic anemia is a condition where the bone marrow fails to produce sufficient numbers of blood cells, including red cells, white cells, and platelets.
B.   Red cells are absent as a result of chronic blood loss. This describes a condition like iron- deficiency anemia, not aplastic anemia.
C.   The bone marrow fails to produce lymphocytes. Aplastic anemia affects the production of all blood cells, not just lymphocytes.
D.   The kidneys fail to produce red blood cells. This describes anemia of chronic kidney disease, not aplastic anemia. In aplastic anemia, the problem lies with the bone marrow, not the kidneys.

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Correct Answer is D

Explanation

A. Pain level of "4" on a scale of 0 to 10 indicates mild pain and may not require immediate attention compared to other potential issues.
B. Vital signs within normal range, including temperature and blood pressure, do not indicate an urgent need for assessment.
C. Urinary catheter output of 150 mL in the last 3 hours is within the expected range postoperatively and does not require immediate assessment.
D. Saturated perineal pads suggest excessive bleeding, which could indicate a potential complication such as hemorrhage. Therefore, the nurse should assess this patient first to ensure prompt intervention if necessary.

A. Risk for Injury related to increased bleeding tendency B. Risk for Infection related to decreased antibody production C. Decreased Cardiac Output related to hypovolemia D. Impaired Gas Exchange related to decreased oxygen-carrying capacity

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.

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Correct Answer is A

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