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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Alcohol can directly suppress the production of red blood cells (erythropoiesis) in the bone marrow, leading to anemia.
B. While alcoholics may indeed be deficient in folate due to poor nutrition, folate deficiency is not the primary mechanism for anemia in alcoholic liver disease.
C. Liver dysfunction can lead to decreased production of clotting factors, contributing to coagulopathy, but it is not the primary mechanism for anemia in alcoholic liver disease.
D. Gastric ulcers may indeed lead to chronic blood loss, contributing to anemia, but it is not specific to alcoholic liver disease.
E. While alcohol-induced inflammation may contribute to various complications, including liver damage, it is not the primary mechanism for anemia in alcoholic liver disease.

A. Three to seven days after menses stops B. Prior to the beginning of menses C. On the second day of menstruation D. On the same day every month

Correct Answer is A

Explanation

A. Three to seven days after menses stops. This is the best time to perform BSE as the breasts are least likely to be swollen and tender during this period.
B. Prior to the beginning of menses. Breasts are more likely to be swollen and tender before menstruation, which can make it harder to detect abnormalities.
C. On the second day of menstruation. During menstruation, hormonal changes can affect breast tissue, making the examination less reliable.
D. On the same day every month. For those with regular menstrual cycles, it is recommended to perform BSE a few days after menses stops for more accurate results.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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