For a client diagnosed with folic acid deficiency anemia who is experiencing activity intolerance, what should the nurse include in the plan of care?
Provide a quiet atmosphere for undisturbed sleep.
Cluster activities in the morning when well-rested.
Identify ways to conserve energy when performing activities.
Recommend small frequent iron-rich meals.
The Correct Answer is C
Choice A Reason
Providing a quiet atmosphere for undisturbed sleep is beneficial for all patients, especially those recovering from illness. However, it does not directly address the issue of activity intolerance. Adequate rest is important, but the primary concern with activity intolerance is managing energy levels during waking hours to improve the patient's ability to engage in activities.
Choice B Reason
Clustering activities in the morning may seem like a good strategy when the patient is well-rested. However, this could lead to rapid depletion of energy reserves and exacerbate activity intolerance. It is more effective to spread activities throughout the day to manage energy levels better.
Choice C Reason
Identifying ways to conserve energy is a key intervention for managing activity intolerance. This can include teaching the patient energy-conservation techniques, such as sitting while showering or dressing, taking frequent breaks, and prioritizing tasks. This approach helps patients with folic acid deficiency anemia to participate in activities without excessive fatigue.
Choice D Reason
While nutrition is important in the management of anemia, recommending small frequent iron-rich meals does not directly address activity intolerance. Folic acid deficiency anemia requires dietary intake of folate-rich foods or supplements. Iron is important, but the focus for folic acid deficiency should be on folate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason:
Being free of chest pain and dyspnea is a significant indicator of successful nursing intervention in a sickle cell crisis. Chest pain and dyspnea can occur due to acute chest syndrome, a life-threatening complication of sickle cell disease characterized by vaso-occlusion in the pulmonary microcirculation. Effective pain management and oxygen therapy can alleviate these symptoms, reflecting improved respiratory function and gas exchange.
Choice B reason:
Educating the client on the importance of increasing fluid intake is crucial in managing sickle cell crisis. Adequate hydration helps to reduce blood viscosity and prevent sickling of red blood cells, which can lead to vaso-occlusive episodes. When a client verbalizes understanding and the importance of hydration, it demonstrates the effectiveness of patient education and the client's engagement in self-care.
Choice C reason:
While increasing aerobic exercises may promote endurance, it is not typically a short-term outcome measure for a sickle cell crisis. Exercise must be approached with caution in these clients, as it can increase the risk of a vaso-occlusive crisis due to dehydration and increased oxygen demand during a sickle cell crisis.
Choice D reason:
Control of acute pain to a level of 3 on a standard pain scale indicates successful pain management, a primary goal in the treatment of sickle cell crisis. Pain in sickle cell crisis is due to ischemia from obstructed blood flow by sickled cells. Effective analgesic administration and pain management strategies are essential to achieve this outcome.
Choice E reason:
A leukocyte count of 18,000/mm³ is above the normal range (4,500 to 11,000/mm³) and may indicate an infection or inflammation, which are common complications of sickle cell disease. However, this is not a direct outcome of nursing interventions aimed at managing a sickle cell crisis and thus is not a correct choice.
Correct Answer is C
Explanation
Choice A Reason
The continuous nature of the mucosa refers to the uninterrupted lining of the urinary tract, which provides a barrier against pathogens. However, this characteristic is not a significant factor in the increased susceptibility of women to cystitis. Both men and women have a continuous mucosal lining, and it does not account for the gender difference in infection rates.
Choice B Reason
High estrogen levels can influence the tissues of the urinary tract and may affect susceptibility to infections. However, the role of estrogen in the development of cystitis is not as direct or significant as anatomical differences. Estrogen levels vary throughout a woman's life and do not consistently correlate with cystitis risk.
Choice C Reason
Urethral proximity to the rectum is the most significant anatomical factor contributing to a woman's increased susceptibility to cystitis¹⁴. Women have a shorter urethra than men, and its close proximity to the anus allows bacteria from the bowel area to more easily enter the urinary tract and cause infections.
Choice D Reason
Inadequate fluid intake can lead to less frequent urination, which is a risk factor for cystitis because it reduces the natural flushing of bacteria from the urinary tract. However, this is a modifiable risk factor and does not inherently explain the higher incidence of cystitis in women compared to men.
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