In helping prepare a nursing care plan for a 90-pound, 82-year-old woman with iron-deficiency anemia with a hemoglobin of 8.2, the nurse agrees that the most appropriate nursing diagnosis would be:
Activity intolerance, related to fatigue.
Disturbed body image, related to weight loss.
Anxiety, related to unfamiliar hospital environment.
Impaired tissue integrity, related to immobility.
The Correct Answer is A
A. Given the low hemoglobin level and weight, the patient is likely experiencing fatigue due to decreased oxygen-carrying capacity of the blood, leading to activity intolerance.
B. While weight loss may contribute to body image disturbance, it is not the primary concern for a patient with iron-deficiency anemia and low hemoglobin levels.
C. Anxiety related to the hospital environment may be present, but it is not the most appropriate nursing diagnosis based on the patient's clinical presentation and laboratory findings.
D. Impaired tissue integrity related to immobility is not the most appropriate nursing diagnosis for a patient with iron-deficiency anemia. This diagnosis is more commonly associated with pressure ulcers or skin breakdown in patients who are immobile for extended periods, which is not described in this scenario.
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Related Questions
Correct Answer is A
Explanation
A. This response accurately describes the pathophysiology of sickle cell crisis. During a crisis, sickled red blood cells clump together, leading to microvascular occlusion and impaired blood flow to tissues, resulting in pain.
B. Bleeding in the joints is not a characteristic feature of sickle cell crisis. It may occur in other conditions such as hemophilia or osteoarthritis but not in sickle cell crisis.
C. Disturbance in cellular metabolism is not the primary mechanism underlying the pain experienced during sickle cell crisis.
D. Bone marrow expansion with sickled cells may contribute to bone pain in sickle cell disease, but it is not the primary cause of pain during a sickle cell crisis.
Correct Answer is D
Explanation
A. Clay: Individuals with pica due to iron-deficiency anemia may crave and consume substances like clay.
B. Soil: Soil consumption is another manifestation of pica commonly seen in individuals with iron-deficiency anemia.
C. Ice: Some individuals with iron-deficiency anemia may crave and chew ice as a form of pica behavior.
D. Any of the responses: Pica is a condition where individuals have cravings for nonfood substances. In iron-deficiency anemia, pica can manifest as cravings for various nonfood items, including clay, soil, ice, and many others.
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