Pernicious Anemia HESI RN case study
1.pernicious anemia case study: John Baker is a 45-year-old Caucasian male who was admitted to the medical-surgical unit 6 hours ago from the Emergency Department due to nausea, vomiting, shortness of breath, pallor, weakness, and severe fatigue. John is divorced with no children and has been practicing law for 15 years. He also has had a medical history of chronic gastric ulcers.
2.The nurse receives shift report and proceeds to Mr. Baker's room, bringing the vital sign measurement equipment. Which vital sign should concern the nurse the most?: Blood pressure is 142/80 mmHg.
Rationale: This elevated blood pressure indicates an underlying issue that must be addressed.
3.The nurse asks Mr. Baker how he is feeling today. He reports that he does not have time for this hospitalization. The nurse notes that he seems annoyed. He coughs as he tries to sit up. He turns on the television, focuses
on a news station, and ignores the nurse.
Which type of assessment should the nurse perform on Mr. Baker?: A focused assessment.
Rationale: This assessment is for evaluating the status of specific previously identi- fied problems and any symptoms of new problems developing
4.: Rationale:
5.The nurse performs a focused assessment. Which systems should the nurse evaluate? (Select all that apply.): Cardiovascular system.
Rationale: The client has hypertension and an elevated heart rate. Respiratory system.
Rationale: The client has a cough.
6.The nurse finds that Mr. Baker has a weak, irregular, and rapid pulse and
his tongue is inflamed. The nurse decides to perform a neurological assessment because of mild tremoring. His unexpected neurological findings included hyperactive deep tendon reflexes and mild burning and prickling sensations on his feet and hands. He also appears to startle easily,
and he has lost about 15% of his weight as compared to his last visit, which was four months ago.
During the assessment, the nurse suspects that the client may have perni- cious anemia. Which pathophysiological process promotes this condition?: - Destruction of gastric parietal cells.
Rationale:
Pernicious anemia is often associated with chronic gastritis. This is because destruc- tion of gastric parietal cells due to inflammation and cellular hypoxia causes gradual gastric atrophy and a reduction of available intrinsic factor, which is a transporter molecule that is required to promote the bioavailability of vitamin B12.
7.The nurse finished documenting the client interview and notices that new laboratory results have been posted in the electronic health record. The nurse notes that the serum magnesium level is 1.0 mEq/L (0.50 mmol/L), and
the normal range is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Which other result will need intervention?: Potassium of 2.9 mEq/L (mmol/L).
Rationale:
This is a low serum potassium level; normal range is 3.5 to 5 mEq/L (mmol/L).
8.Which action is most important for the nurse to perform before calling the healthcare provider to report the lab values?: Initiate telemetry.
Rationale: Although telemetry does require a healthcare provider's prescription, most hospitals have a standing order in place for situations
such as this one.
Telemetry placement is essential to protect the client from potential
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