A 44-year-old female client presents to the emergency department with abnormal bleeding and abdominal pain that is later attributed to gallbladder disease. Which diagnosis would the medical team be most justified in suspecting as a cause of the client’s bleeding?
Selected Answer:
A.
Vitamin K deficiency
Answers:
A.
Vitamin K deficiency
B.
Excess calcium
C.
Idiopathic immune thrombocytopenic purpura (ITP)
D.
Hemophilia B
Response Feedback:
Rationale: Factors VII, IX, and X and prothrombin require the presence of vitamin K for normal activity. Vitamin K deficiency may result from impaired fat absorption caused by liver or gallbladder disease. Calcium, factors X and V, and platelet phospholipids combine to form prothrombin activator, which then converts prothrombin to thrombin. Excess calcium could result in increased formation of blood clots. Hemophilia B is a hereditary disorder. Half of the cases of ITP occur as an acute disorder in children; ITP in adults is a chronic disorder with insidious onset.
Question 2
2 out of 2 points
A 30-year-old woman who has given birth 12 hours prior is displaying signs and symptoms of disseminated intravascular coagulation (DIC). The client’s husband is confused as to why a disease of coagulation can result in bleeding. Which statement by the nurse best characterizes DIC?
Selected Answer:
D.
“So much clotting takes place that there are no available clotting components left, and bleeding ensues.”
Answers:
A.
“Massive clotting causes irritation, friction, and bleeding in the small blood vessels.”
B.
“These same hormones and bacteria that cause clotting also cause bleeding.”
C.
“Excessive activation of clotting causes an overload of vital organs, resulting in bleeding.”
D.
“So much clotting takes place that there are no available clotting components left, and bleeding ensues.”
Response Feedback:
Rationale: DIC hemorrhage results from an insufficiency of clotting proteins after large scale coagulation. It is not a result of physical irritation, organ overload, or bacteria and hormones.
Question 3
2 out of 2 points
A 36-year old woman with a diagnosis of antiphospholipid syndrome is receiving a scheduled checkup from her nurse practitioner. Which teaching point would the nurse most likely prioritize?
Selected Answer:
C.
“We need to ensure your birth control pills don’t contain estrogen.”
Answers:
A.
“Good nutrition and blood sugar control are important in your case.”
B.
“You’ll need to avoid taking nonsteroidal anti-inflammatory drugs when you have menstrual cramps.”
C.
“We need to ensure your birth control pills don’t contain estrogen.”
D.
“It’s important for you to do regular physical activity and maintain a healthy body weight.”
Response Feedback:
Rationale: Estrogen-containing birth control pills can predispose individuals with antiphospholipid syndrome to a thrombotic event. Exercise, nutrition, and blood sugar control are not particularly associated with management of antiphospholipid syndrome, and nonsteroidal anti-inflammatory drugs have no noted relevance to the disease.
Question 4
2 out of 2 points
Two nursing students are attempting to differentiate between the presentations of immune thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP). Which of the students’ statements best captures an aspect of the two health problems?
Selected Answer:
D.
“Both of them involve low platelet counts, but in TTP there can be more, not less, hemostasis.
Answers:
A.
“TTP can be treated with plasmapheresis, but ITP is best addressed with transfusion of fresh frozen plasma.”
B.
“ITP can be either inherited or acquired, and if it’s acquired, it involves an enzyme deficiency.”
C.
“Both diseases can result from inadequate production of thrombopoietin by megakaryocytes.
D.
“Both of them involve low platelet counts, but in TTP there can be more, not less, hemostasis.
Response Feedback:
Rationale: TTP is marked by sudden and severe thrombotic involvement. Neither disease has an etiology of low thrombopoietin production, and TTP, not ITP, is rooted in an enzyme deficiency. ITP is normally treated with corticosteroids and/or immunoglobulins.
Question 5
2 out of 2 points
Which clients would be at risk for developing nonthrombocytopenic purpura? Select all that apply.
Selected Answers:
A.
Child adopted from India and displaying malaise, lethargy, and petechiae all over the body associated with suspected scurvy.
B.
55-year-old client diagnosed with Cushing disease displaying bruises, weight gain with a buffalo hump, and “moon” face
Answers:
A.
Child adopted from India and displaying malaise, lethargy, and petechiae all over the body associated with suspected scurvy.
B.
55-year-old client diagnosed with Cushing disease displaying bruises, weight gain with a buffalo hump, and “moon” face
C.
15-year-old with insulin-dependent diabetes who has hypoglycemia and is displaying irritability with headaches and tachycardia
D.
Pregnant mother experiencing headaches and proteinuria
E.
73-year-old client admitted with concussion that resulted from a fall
Response Feedback:
Rationale: Vascular disorders that cause bleeding include vitamin C deficiency, Cushing disease, senile purpura, aging process. Concussion and insulin-dependent diabetes do not result in weak vessel walls initially. A pregnant mother experiencing headaches and proteinuria is associated with preeclampsia.
Question 6
2 out of 2 points
The nurse is caring for a client who has been on an oral corticosteroid for several years for an autoimmune condition. The nurse notes several bruises of different stages of resolution on the client. What is the nurse’s best response to this finding?
Selected Answer:
C.
Interview the client regarding side effects of corticosteroid therapy.
Answers:
A.
Request an order for vitamin K to prevent life-threatening hemorrhage.
B.
Obtain a STAT order for repeat platelet count and international normalized ratio (INR).
C.
Interview the client regarding side effects of corticosteroid therapy.
D.
Complete a thorough pain assessment related to the bruising.
Response Feedback:
Rationale: Clients on corticosteroid therapy develop a form of iatrogenic Cushing syndrome. This syndrome causes many symptoms for which the nurse should assess, and easy bruising is directly related to the client’s therapy. Excess cortisol causes protein wasting and loss of vessel tissue support, leading to a nonthrombocytopenic purpura. This is characterized by easy bruising and the spontaneous appearance of petechiae and purpura of the skin and mucous membranes. In this case, the INR and platelet count would be normal. While pain assessments should be performed for any client, this is not relevant to the bruises related to this risk factor.
Question 7
2 out of 2 points
A medical student is familiarizing herself with recent overnight admissions to an acute medical unit of a university hospital. Which client would the student recognize as least likely to have a diagnosis of antiphospholipid syndrome in his or her medical history?
Selected Answer:
A.
A 21-year-old male with a diagnosis of cellulitis and suspected endocarditis secondary to intravenous drug use
Answers:
A.
A 21-year-old male with a diagnosis of cellulitis and suspected endocarditis secondary to intravenous drug use
B.
A 66-year-old obese male with left-sided hemiplegia secondary to a cerebrovascular accident
C.
A 90-year-old female resident of a long-term care facility who has been experiencing transient ischemic attacks
D.
A 30-year-old female with a diagnosis of left leg deep vein thrombosis and a pulmonary embolism
Response Feedback:
Rationale: Stroke, transient ischemic attacks, deep vein thrombosis, and pulmonary emboli are all common manifestations of the hypercoagulability associated with antiphospholipid syndrome. Cellulitis, endocarditis, and other infectious processes would be less likely to correlate with antiphospholipid syndrome.
Question 8
2 out of 2 points
In which client would diagnostic investigations be least likely to reveal increased thrombopoietin production?
Selected Answer:
C.
A 21-year-old woman awaiting bone marrow transplant for myelogenous leukemia
Answers:
A.
A 66-year-old woman with a diagnosis of lung cancer with bone metastases
B.
A 55-year-old man with dehydration secondary to Crohn disease
C.
A 21-year-old woman awaiting bone marrow transplant for myelogenous leukemia
D.
An 81-year-old woman with diagnoses of rheumatoid arthritis and failure to thrive
Response Feedback:
Rationale: Diseases such as myelogenous leukemia and other cases of primary thrombocytosis result in abnormalities in the thrombopoietin receptor and platelet binding. Cases of secondary thrombocytosis have an etiology rooted in increased thrombopoietin production. The common underlying causes of secondary thrombocytosis include tissue damage due to surgery, infection, cancer, and chronic inflammatory conditions such as rheumatoid arthritis and Crohn disease.
Question 9
2 out of 2 points
A client with leukemia begins hemorrhaging from every orifice. The physician is concerned that the client has developed disseminated intravascular coagulation (DIC). The nurse should anticipate which order to be prescribed for this client? Select all that apply.
Selected Answers:
A.
Transfuse 2 units of platelets.
E.
Transfuse fresh frozen plasma.
Answers:
A.
Transfuse 2 units of platelets.
B.
Place in reverse isolation.
C.
Administer IV ketorolac STAT.
D.
Give aspirin twice/day.
E.
Transfuse fresh frozen plasma.
Response Feedback:
Rationale: The treatment of DIC is directed toward managing the primary disease, replacing clotting components, and preventing further activation of clotting mechanisms. Transfusions of fresh frozen plasma, platelets, or fibrinogen-containing cryoprecipitate may correct the clotting factor deficiency. ASA would make the bleeding worse. Ketorolac is an NSAID and should be avoided in clients with a bleeding problem. Reverse isolation is implemented for clients with pancytopenia.
Question 10
2 out of 2 points
After assessment, the nurse asks how long the client has had red, pinpoint hemorrhages on the lower legs. The client responds, “This is the first time I have noticed this. What is wrong with me that is causing these small hemorrhages?” Which response by the nurse is most accurate?
Selected Answer:
C.
“These hemorrhages are called petechiae and occur when platelets are deficit.”
Answers:
A.
“Your platelets are developing a deformity as they are being produced by the bone marrow.”
B.
“You might have a pooling of all your platelets in the spleen. I will assess for that next.”
C.
“These hemorrhages are called petechiae and occur when platelets are deficit.”
D.
“More than likely, you bumped something and these are a result of trauma to the vessel.”
Response Feedback:
Rationale: Bleeding because of platelet disorders reflects a decrease in platelet number because of decreased production, increased destruction, or impaired function of platelets. Spontaneous bleeding from platelet disorders most often involve small vessels of the mucous membranes and skin. Cutaneous bleeding is seen as pinpoint hemorrhages (petechiae) and purple areas of bruising (purpura) in dependent areas where capillary pressure is higher. Petechiae are seen almost exclusively in conditions of platelet deficiency and not platelet dysfunction. Bruising can be caused by trauma (bumping into items), but not the development of petechiae. The spleen routinely house 30% to 40% of the platelets before releasing into circulation. Large portions of platelets cause splenomegaly and is treated with splenectomy.
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