Exam (elaborations)
Chapter 48 Hematological or Immunological Dysfunction
- Course
- Maternal child nursing
- Institution
- Rutgers School Of Nursing
Chapter 48 Hematological or Immunological Dysfunction
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Chapter 48: Hematological or Immunological DysfunctionMULTIPLE CHOICE
1. Which statement accurately describes anemia?
a. Increased blood viscosity
b. Depressed hematopoietic system
c. Presence of abnormal hemoglobin
d. Decreased oxygen-carrying capacity
of blood
ANS: D
Anemia is a condition in which the number of red blood cells or hemoglobin concentration is
reduced below the normal values for age. This results in blood having a decreased oxygen-
carrying capacity. Increased blood viscosity is usually a function of too many cells or
dehydration, not anemia. A depressed hematopoietic system or abnormal hemoglobin can
contribute to anemia, but the definition depends on the decreased oxygen-carrying capacity of
the blood.
DIF: Cognitive Level: Comprehension REF: p. 1523
OBJ: Nursing Process: Assessment
2. Several blood tests are ordered for a preschool child with severe anemia. She is crying and
upset because she remembers the venipuncture done at the clinic 2 days ago. What should the
nurse explain to the child?
a. Venipuncture discomfort is very brief.
b. Only one venipuncture will be needed.
c. Topical application of local anaesthetic
can eliminate venipuncture pain.
d. Most blood tests on children require
only a finger puncture because a small
amount of blood is needed.
ANS: C
Preschool children are very concerned about both pain and loss of blood. When preparing the
child for venipuncture, a topical anaesthetic (e.g., EMLA) should be used to eliminate any pain
and a bandage should be applied afterward. This is a traumatic experience for preschool
children because they are concerned about their bodily integrity. The nurse should not
promise that only one venipuncture will be needed, in case multiple attempts are required.
, Both finger punctures and venipunctures are traumatic for children, so both require
preparation.
DIF: Cognitive Level: Application REF: p. 1526 OBJ: Nursing
Process: Implementation
3. What is the most appropriate nursing diagnosis for a child with anemia?
a. Activity intolerance related to
generalized weakness
b. Decreased cardiac output related to
abnormal hemoglobin
c. Risk for injury related to depressed
sensorium
d. Risk for injury related to dehydration
and abnormal hemoglobin
ANS: A
The basic pathology in anemia is the decreased oxygen-carrying capacity of the blood. The
nurse must assess the child’s activity level (response to the physiological state), and the
nursing diagnosis would reflect activity intolerance. In generalized anemia, no abnormal
hemoglobin may be present—only at a level of very severe anemia is cardiac output altered.
No decreased sensorium exists until profound anemia occurs.
Dehydration and abnormal hemoglobin are not usually part of anemia.
DIF: Cognitive Level: Analysis REF: p. 1523 | p. 1525 OBJ:
Nursing Process: Diagnosis
4. Why is iron-deficiency anemia common during toddlerhood?
a. Milk is a poor source of iron.
b. Iron cannot be stored during fetal
development.
c. Fetal iron stores are depleted by age 1
month.
d. Dietary iron cannot be started until
age 12 months.
ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cow’s milk is a
major component of their diet and it is a poor source of iron. Iron is stored during fetal
development, but the amount stored depends on maternal iron stores. Fetal iron stores are
, usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-
fortified formula, and cereals during the first 12 months of life.
DIF: Cognitive Level: Analysis REF: p. 1527
OBJ: Nursing Process: Assessment
5. What information should the nurse include when teaching the mother of a 9-month-old infant
about administering liquid iron preparations?
a. They should be given with meals.
b. They should be stopped immediately if
nausea and vomiting occur.
c. Adequate dosage will turn the stools a
tarry green colour.
d. The preparation should be allowed to
mix with saliva and bathe the teeth
before swallowing.
ANS: C
The nurse should prepare the mother for the anticipated change in the child’s stools. If the iron
dose is adequate, the stools will be a tarry green colour. The lack of the colour change may
indicate insufficient iron. The iron should be given in two divided doses between meals, when
the presence of free hydrochloric acid is greatest, because iron is absorbed best in an acidic
environment. Vomiting and diarrhea may occur with iron administration. If these occur, iron
should be given with meals at a reduced dosage, and gradually increased as the child develops
tolerance. Liquid preparations of iron stain the teeth, so they should be administered through
a straw and the mouth rinsed after administration.
DIF: Cognitive Level: Analysis REF: p. 1528
OBJ: Nursing Process: Implementation
6. Which age group is most at risk for iron-deficiency anemia?
a. Term infant
b. School-aged children
c. Adolescent
d. Young adult
ANS: C
Adolescents are most at risk because of their rapid growth rate combined with poor eating
habits. Preterm infants, not term infants, are especially at risk because of their reduced fetal
iron supply. Healthy school-aged children and young adults are not at high risk.
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