lOMoARcPSD|3013804
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Chapter 36 notes
Care Management (Keiser
University)
, lOMoARcPSD|3013804
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 36: Assessment of the Hematologic System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is assessing an older client for any potential hematologic health problem. Which
assessment finding is the most significant and would be reported to the primary health care
provider?
a.
Poor skin turgor on both forearms
b.
Multiple petechiae and large bruises
c.
Dry, flaky skin on arms and legs
d.
Decreased body hair distribution
ANS: B
The presence of multiple petechiae and large bruises indicate a possible problem with blood
clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased
body fluid as a result of aging. They also lose body hair or have thinning hair as a normal
change of aging.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Nursing assessment, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
2. A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best
to assess for pallor in this client?
a.
Assess the conjunctiva of the eye.
G R A D E S L AB.COM
b.
Have the patient open the h an d w i de ly .
c.
Look at the roof of the patient’s mouth.
d.
Palpate for areas of mild swelling.
ANS: A
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous
membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is
not related to pallor, nor is palpating for mild swelling.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Nursing assessment, Anemia
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A hospitalized client has a platelet count of 58,000/mm3 (58 109/L). What action by
the nurse is most appropriate?
a.
Encourage high-protein foods.
b.
Institute neutropenic precautions.
c.
Limit visitors to healthy adults.
d.
Place the client on safety precautions.
ANS: D
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Chapter 36 notes
Care Management (Keiser
University)
, lOMoARcPSD|3013804
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 36: Assessment of the Hematologic System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is assessing an older client for any potential hematologic health problem. Which
assessment finding is the most significant and would be reported to the primary health care
provider?
a.
Poor skin turgor on both forearms
b.
Multiple petechiae and large bruises
c.
Dry, flaky skin on arms and legs
d.
Decreased body hair distribution
ANS: B
The presence of multiple petechiae and large bruises indicate a possible problem with blood
clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased
body fluid as a result of aging. They also lose body hair or have thinning hair as a normal
change of aging.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Nursing assessment, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
2. A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best
to assess for pallor in this client?
a.
Assess the conjunctiva of the eye.
G R A D E S L AB.COM
b.
Have the patient open the h an d w i de ly .
c.
Look at the roof of the patient’s mouth.
d.
Palpate for areas of mild swelling.
ANS: A
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous
membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is
not related to pallor, nor is palpating for mild swelling.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Nursing assessment, Anemia
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A hospitalized client has a platelet count of 58,000/mm3 (58 109/L). What action by
the nurse is most appropriate?
a.
Encourage high-protein foods.
b.
Institute neutropenic precautions.
c.
Limit visitors to healthy adults.
d.
Place the client on safety precautions.
ANS: D
