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1

Iron deficiency typically manifests as:

  1. Macrocytic, normochromic anemia.
  2. Microcytic, hypochromic anemia.
  3. Microcytic, normochromic anemia.
  4. Normochromic, normocytic anemia.

2. Microcytic, hypochromic anemia.

Iron deficiency results in the development of cells that are smaller in size (microcytic) and more pale in color (hypochromic) due to the lack of Hgb during cell synthesis. In the early phases of iron deficiency, cells may actually remain normocytic and normochromic because the bone marrow draws upon stored iron reserves during erythropoiesis. Once the stores have been depleted, the production the erythrocytes formed become microcytic and hypochromic.

2

A 20-year-old college student presents with complaints of excessive fatigue, fever, and exudative pharyngitis, which is accompanied by anterior and posterior cervical lymphadenopathy. What WBC findings would support the suspected diagnosis?

  1. Increased neutrophils with more than 10% bands
  2. Increased lymphocytes with more than 10% atypical lymphocytes
  3. Increased total leukocytes, with an increased proportion of basophils
  4. Increased total leukocytes, with an increased proportion of eosinophils

2. Increased lymphocytes with more than 10% atypical lymphocytes

The case scenario is consistent with the classic triad seen with infectious mononucleosis: fever, exudative pharyngitis, and adenopathy. Within mono, the characteristic CBC findings include absolute lymphocytosis in which more than 10% of the cells are atypical.

3

Which of the following laboratory findings are most consistent with anemia related to folic acid deficiency?

  1. Decreased MCV and decreased MCHC
  2. Decreased MCV and normal MCHC
  3. Increased MCV and normal MCHC
  4. Normal MCV and normal MCHC

3. Increased MCV and normal MCHC

Folic acid deficiency results in impaired RNA and DNA synthesis within the developing erythrocyte and the development of immature and dysfunctional enlarged RBCs (megaloblasts). Because hemoglobin synthesis is not impaired, RBCs formed in the presence of folic acid deficiency retain their normal concentration of hemoglobin (MCHC) and normal color.

4

The FNP is evaluating a CBC that reveals an abnormally low Hgb, Hct, and RBC count. Which of the following lab values would assist the FNP in determining if the anemia was microcytic or macrocytic?

  1. Ferritin level
  2. MCV
  3. MCHC
  4. TIBC

2. MCV

The mean cell volume is the lab value that reflects RBC size or average volume. Based on MCV, cells are classified as normocytic (80–100 femtoliters [fL]), microcytic ( 100 fL).

5

Which of the following conditions is associated with normocytic anemia?

  1. A deficiency in vitamin B12 intake or absorption
  2. Chronic blood loss
  3. Concurrent chronic illness (i.e., chronic kidney disease)
  4. Inadequate globin synthesis

3. Concurrent chronic illness (i.e., chronic kidney disease)

Normocytic anemia, with an MCV of 80–100fL, correlates with anemia of chronic disease. Chronic blood loss is associated with iron deficiency anemia, a microcytic anemia. Deficiency in vitamin B12 results in the development of macrocytic anemia. Inadequate globin synthesis occurs in beta thalassemia, a microcytic anemia.

6

The FNP is following up with a patient previously diagnosed with anemia who complains of a sore tongue and numbness and tingling of the hands and feet. The FNP recognizes that she needs to address the patient’s response to:

  1. Administration of erythropoietin.
  2. Ferrous sulfate supplementation.
  3. Folic acid supplementation.
  4. Vitamin B12 supplementation.

4. Vitamin B12 supplementation.

The case presentation is that of vitamin B12 deficiency. Although glossitis may occur with folic acid deficiency, parasthesias of the hands and feet in a stocking/glove distribution are characteristic of pernicious anemia; thus, it is important to evaluate the patient’s response to vitamin B12 supplementation.

7

The FNP is following up with a young adult woman previously diagnosed with microcytic, hypochromic anemia. The FNP recognizes that it is important to rule out:

  1. Abnormal uterine bleeding.
  2. Gastrointestinal bleeding.
  3. Inadequate intake of folic acid.
  4. Low carbohydrate diet fads.

1. Abnormal uterine bleeding.

In young adult women, abnormal uterine bleeding is a common cause of iron deficiency anemia, a microcytic, hypochromic anemia. Bleeding from the GI tract is a more common cause of IDA in older adults. Inadequate intake of folic acid would result in macrocytic anemia. Low carbohydrate diets still allow for adequate intake of iron from meats and green leafy vegetables.

8

What laboratory finding on the white blood cell count would lead the nurse practitioner to suspect acute appendicitis as the cause of a client’s right lower quadrant abdominal pain?

  1. Increased lymphocytes with more than 10% atypical lymphs
  2. Increased neutrophils with more than 10% bands
  3. Increased total leukocytes, with an increased proportion of basophils
  4. Increased total leukocytes, with an increased proportion of eosinophils

1. Increased lymphocytes with more than 10% atypical lymphs

Acute infectious processes stimulate an increase in the production and release of mature neutrophils and mobilization of less mature neutrophils or bands. Normally, the vast majority of neutrophils circulating in the bloodstream are in the mature form, but with acute infectious processes, mobilization of bands can increase the proportion of immature neutrophils to greater than 10%.

9

When interpreting findings in an individual with leukocytosis, the FNP recognizes that a "left shift" is represented by an increase in the proportion of:

  1. Eosoniphils.
  2. Lymphocytes.
  3. Monocytes.
  4. Neutrophils.

4. Neutrophils.

The term "left shift" is almost always associated with neutrophils. The left shift means that the population of cells is shifted toward most immature cells, with an increased percentage of immature neutrophils (i.e., bands, metamyeloctyes, and myelocytes) being present to fight infection.

10

What organ system is responsible for the majority of the body’s production of erythropoietin?

  1. Bone Marrow
  2. Kidneys
  3. Liver
  4. Spleen

2. Kidneys

90% of the body’s erythropoietin is produced by the kidneys; only about 10% is produced in the liver.

11

An elevated red cell distribution width (RDW) correlates with which of the following findings on the peripheral smear?

  1. Anisocytosis
  2. Microcytosis
  3. Poikilocytosis
  4. Reticulocytosis

1. Anisocytosis

Anisocytosis describes variance in RBC sizes that is common in anemia as new cells formed are larger (macrocytic) or smaller (microcytic) than the healthy cells which were formed prior to the underlying processes that resulted in anemia. This variance in sizes of circulating red blood sizes correlates with an increased RDW.

12

Women of childbearing age should have an adequate intake of what micronutrient to decrease the risk of fetal neural tube defects?

  1. Folic acid
  2. Iron
  3. Vitamin B6
  4. Vitamin B12

1. Folic acid

Folic acid deficiency in early pregnancy has been linked to the teratogenic effect of neural tube defects.

13

The most appropriate additional diagnostic test for the patient with decreased WBCs, RBCs, and platelets is a:

  1. Bone marrow biopsy.
  2. Direct Coombs’ test.
  3. Hemoglobin electrophoresis.
  4. Serum haptoglobin.

1. Bone marrow biopsy.

Pancytopenia (a deficiency in all three cellular components of the blood) is indicative of aplastic anemia. A bone marrow aspiration biopsy is needed to rule out myelodysplastic syndrome and metastatic tumor deposits. The hypoplastic bone marrow of aplastic anemia will have fatty replacement which is often accompanied by a relative increase in nonhematopoietic elements (i.e., mast cells).

14

The presence of schistocytes on the peripheral smear of a patient with decreased platelets should raise the suspicion of:

  1. Autoimmune hemolytic anemia.
  2. Erythroblastisfetalis.
  3. Thalassemia major.
  4. Thrombotic thrombocytopenic purpura.

4. Thrombotic thrombocytopenic purpura.

Thrombotic thrombocytopenic purpua is a microangiopathic hemolytic anemia that is accompanied by systemic microvascular thrombosis that can impact any organ(s) within the body. Within this potentially fatal condition, RBCs within the circulation become severed as they come in contact with thrombi within the vessels. The remaining fragmented cell is known as schistocyte. An initial schistocyte count of greater than 1% strongly suggests a diagnosis of TTP in the absence of other known causes of thrombotic microangiopathy.

15

The FNP is educating an anemic patient about the procedure(s) for a Schilling test. The practitioner recognizes that a Schilling test involves:

  1. An early morning, fasting lab draw.
  2. Collecting urine for 24 hours.
  3. Endoscopic sampling of the gastric mucosa.
  4. Serial collections of serum vitamin B12 levels.

2. Collecting urine for 24 hours.

The Schilling test is used to determine whether the body absorbs vitamin B12 normally. Patients undergoing testing receive two doses of vitamin B12: The first is an oral radioactive form; an intramuscular injection of non-radioactive vitamin B12 is administered one hour later. The patient then collects urine over the next 24 hours, and the specimen is evaluated to determine how much vitamin B12 is excreted in the urine.

16

What is the most likely diagnosis for a patient with the following CBC findings?: WBC: 7.1 × 103/µl; RBC: 3.32 × 103/µl; Hgb: 11.3 g/Dl; Hct: 34.4%; MCV: 91 fL; MCHC: 32 g/dL;Plt: 364 × 103/µl; RDW: 13.4%; Reticulocytes: 0.9%.

  1. Anemia of chronic disease
  2. Folate deficiency anemia
  3. Iron deficiency anemia
  4. Vitamin B12 deficiency anemia

1. Anemia of chronic disease

The MCV of this patient with anemia reveals a normocytic anemia. Iron deficiency anemia is a microcytic anemia, while folic acid and vitamin B12 deficiencies result in the production of RBCs that are larger in size than normal cells, macrocytic anemia.

17

What is the most likely diagnosis for a patient with the following CBC findings?: WBC: 8.8 × 103/µl; RBC: 3.01 × 103/µl; Hgb: 10.3 g/dL; Hct: 32.2%; MCV: 74 fL; MCHC: 28.3 g/dL; Plt: 400 × 103/µl; RDW: 18.4%; Reticulocytes: 2.1%.

  1. Anemia of chronic disease
  2. Folate deficiency anemia
  3. Iron deficiency anemia
  4. Vitamin B12 deficiency anemia

3. Iron deficiency anemia

The MCV of this patient with anemia reveals a microcytic anemia. Anemia of chronic disease is most commonly a normocytic anemia, while folic acid and vitamin B12 deficiencies result in the production of RBCs that are larger in size than normal cells, which is called macrocytic anemia.

18

Which diagnostic test could help identify whether the cause of anemia is hemolytic in nature?

  1. Bone marrow aspiration
  2. Direct antiglobulin test
  3. Hemoglobin electrophoresis
  4. Serum haptoglobin

4. Serum haptoglobin

Standard blood tests for the workup of suspected hemolytic anemia include a CBC with peripheral smear, serum LDH, serum haptoglobin, and indirect bilirubin. Changes in the LDH and serum haptoglobin are the most sensitive of these tests. Within intravascular hemolysis, free hemoglobin is released into the circulation and quickly bound by haptoglobin; thus, circulating haptoglobin levels decline.

19

The lab index that has demonstrated reliability as an early marker of microcytic and macrocytic anemias is the:

  1. MCH.
  2. MCHC.
  3. MCV.
  4. RDW.

4. RDW.

An increase in RDW beyond the normal range of 15% is seen in early attempts to maintain hematologic homeostasis. Marked reticulocytosis results in transient changes to the RDW because the reticulocytes differ in size from the cells produced under healthy conditions.

20

The FNP is seeing a patient who has been taking ferrous sulfate. Which statement by the patient demonstrates a need for additional education?

  1. "I should take my medication with orange juice to increase absorption."
  2. "I should take one tablet twice a day."
  3. "It is best to take the iron on an empty stomach."
  4. "It is recommended that I take enteric coated iron with meals."

4. "It is recommended that I take enteric coated iron with meals."

Iron is best absorbed when taken on an empty stomach, but does have GI effects that limit tolerability (i.e., nausea and epigastric discomfort); taking iron supplementation with food can decreased absorption by two-thirds and the use of enteric-coated preparations limits the absorption in the duodenum. Ascorbic acid does enhance iron absorption in the GI tract.

21

An older adult with ESRD who is undergoing hemodialysis is in the office for follow-up. The patient is on erythropoietin therapy, but has not been able to attain a hemoglobin level greater than 9.2 g/dL despite negative assessment for blood loss and other common etiologies known to contribute to hyporesponsiveness to erythropoietin. The patient’s haptoglobin and LDH are elevated. Which of the following causes of hemolysis is most likely contributing to the patient’s anemia?

  1. Autoimmune
  2. Drug-induced
  3. Hereditary
  4. Mechanical

4. Mechanical

Patients undergoing hemodialysis are at risk for physical damage to the RBC membranes because it causes them to break down faster than normal. Autoimmune hemolytic anemia is linked to specific diseases (lupus, hepatitis, leukemia, and lymphoma) and infections (EBV, CMV, and HIV). Drug-induced hemolytic anemia is linked to chemotherapy, quinine and antimalarial medications, levodopa, and anti-inflammatories, among others). Hereditary or inherited hemolytic anemias (including sickle cell anemia, thalassemia, G6PD deficiency, and hereditary spherocytosis and elliptocytosis) most commonly have manifestations that begin earlier in the lifespan.

22

Which of the following is the leading cause of death in individuals with sickle cell anemia?

  1. Bacterial infection
  2. Heart failure
  3. Kidney failure
  4. Stroke

1. Bacterial infection

Although the risk of bacterial infections does decrease in the individual with sickle cell anemia after the age of three years, bacterial infections are still the most common cause of death at any age.

23

When evaluating the patient with megaloblastic anemia who does not have neurological symptoms, the FNP recognizes that the most likely diagnosis is:

  1. An underlying hemolytic process.
  2. Folic acid deficiency.
  3. Iron deficiency.
  4. Suppression of the bone marrow.

2. Folic acid deficiency.

Megaloblastic anemia correlates with macrocytic anemia. Of the macrocytic anemias, vitamin B12 commonly produces a variety of neurological symptoms because of its relationship with methylmalonic acid and methionine, while folic acid deficiency does not manifest with neurological symptoms.

24

An older adult who has been hospitalized with macrocytic anemia with an Hgb of 8 g/dl is being seen for follow-up. Because of the degree of anemia, daily vitamin B12 injections for one week have been ordered. What additional labs will be drawn during this follow-up visit?

  1. Calcium level
  2. Creatinine and BUN
  3. Fasting glucose
  4. Potassium level

4. Potassium level

Vitamin B12 replacement is accompanied by a shift of potassium from the serum to within the cells during reticulocytosis; the risk for hypokalemia is more common in the individual with severe anemia and can be compounded by coexisting conditions or medications that place the individual at risk for hypokalemia or the negative consequences associated with this electrolyte imbalance (e.g., those on diuretics or digoxin).

25

The gold standard for diagnosing sickle cell disease is a(n):

  1. Bone marrow aspiration.
  2. Direct antiglobin test.
  3. Hemoglobin electrophoresis.
  4. Indirect Coombs’ test.

3. Hemoglobin electrophoresis.

Hemoglobin electrophoresis identifies variant and abnormal hemoglobins, including hemoglobin S (HbS) or sickle hemoglobin. It can be used to differentiate those who have sickle cell disease (in which at least one of the two abnormal inherited genes will result in the production of hemoglobin S) and sickle cell anemia (in which the individual has inherited two hemoglobin S genes, hemoglobin SS [HbSS], the most common and severe type of the disease).

26

What therapy is commonly used to prevent acute pain syndrome in children and adults with SCD?

  1. Hydroxyurea
  2. Ibuprofen
  3. Intravenous iron infusions
  4. Monthly blood transfusions

1. Hydroxyurea

Several studies in children and adults have revealed that hydroxyurea reduces the number of episodes of vaso-occlusive or pain crises and hospitalizations. Therapy with hydroxyurea has also been shown to decrease the need for transfusions. Experts recommend that children and adults with hemoglobin SS who have frequent, painful episodes, recurrent chest crises, or severe anemia requiring transfusions take hydroxyurea daily. Some experts initiate this therapy to all hemoglobin SS children over the age of 9 months to prevent or reduce the chance of complications; safety and effectiveness in children under the age of 9 months has not been established. Ibuprofen is helpful when mild pain crises occur.

27

A seven-year-old boy, recently diagnosed with acute lymphocytic leukemia (ALL), has been receiving induction chemotherapy treatments. Current lab values indicate a WBC count of 4,300/mm3, neutrophils 50%, lymphocytes 15%, monocytes 2%, eosinophils 3%, and basophils 1%. What is his absolute neutrophil count (ANC)?

  1. 86/mm3
  2. 645/mm3
  3. 2,150/mm3
  4. 3,440/mm3

3. 2,150/mm3

The absolute neutrophil count (ANC) refers to the number of neutrophil granulocytes in the blood and is utilized as a measure of risk for infection in patients undergoing chemotherapy. The ANC is calculated by multiplying the WBC count by the percent of neutrophils (segs and bands) present in the blood. The ANC can be interpreted as follows: ANC greater than 1500/mm3: No increased risk of infection; ANC 1000–1500/mm3: Slight increase in risk of infection; ANC 500–1000/mm3: Moderate increase in risk of infection; ANC 100–500/mm3: High risk of infection; ANC less than 100/mm3: Extremely high risk of infection

28

A 19-year-old male has beta thalassemia major, which was detected during infancy. He receives frequent RBC transfusions for severe anemia. Which of the following supplements should the patient avoid?

  1. Folic acid
  2. Multi-vitamins with iron
  3. Vitamin B12
  4. Vitamin C

2. Multi-vitamins with iron

Iron overload is a major concern for transfusion-dependent patients with thalassemia major, contributing to morbidity and mortality. Each unit of transfused blood has approximately 250 mg of iron, which accumulates in the tissues, especially the liver and heart. Thalassemia major patients commonly undergo iron chelation therapy to minimize their risk of transfusion-induced iron overload complications. Supplementation with iron should be avoided unless there is substantial evidence of an iron deficiency.

29

A mother of an exclusively breast fed 4-month-old infant presents to the nurse practitioner for a well-child examination. Which of the following recommendations is appropriate at this time to reduce the risk for iron deficiency anemia in the infant?

  1. Begin supplementation with an iron-rich formula.
  2. Have the mother take an iron supplement.
  3. Initiate an oral multivitamin with iron for the baby.
  4. Introduce iron-rich foods for the baby.

3. Initiate an oral multivitamin with iron for the baby.

The American Academy of Pediatrics (2010) identifies that iron deficiency anemia is a common yet undetected problem among children. Current recommendations include universal iron supplementation for all children, with dosing dependent on the child’s age and the anticipated amount of iron consumed. Term, healthy infants have sufficient iron for the first 4 months of life. Human breast milk contains very little iron, and therefore, breastfed infants should be supplemented with 1 mg/kg per day of oral iron from 4 months of age until iron-rich foods are introduced. Formula-fed infants receive adequate iron from formula and complementary foods, and supplementation is not required.

30

A 20-year-old African American male was recently treated for a minor skin infection with sulfamethoxazole/trimethoprim DS twice daily for 10 days. He returns to the clinic complaining of fatigue, yellowing of his skin and eyes, and dark urine. These symptoms lead the nurse practitioner to suspect which of the following?

  1. G6PD deficiency
  2. Pernicious anemia
  3. Sickle cell disease
  4. Thalassemia

1. G6PD deficiency

Glucose-6-Phosphate Dehydrogenase deficiency is a genetic disorder in which the body doesn’t have enough of the G6PD enzyme to help protect the RBCs from oxidative insult. The most common presentation is hemolytic anemia, leading to symptoms of jaundice, pallor, fatigue, dark urine, tachycardia, and dyspnea. G6PD is on the X chromosome and tends to affect more men than women. The hemolytic anemia is most often triggered by an oxidative stressor such as bacterial or viral infections and certain medications (sulfonamides, analgesics, antimalarials, antihelminths). Hemolytic anemia can also occur after eating fava beans or inhaling pollen from fava plants (a reaction called favism), or exposure to mothballs.