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. Prolonged bleeding or easy bruising is a characteristic feature of hemophilia, a genetic
disorder characterized by deficient or defective blood clotting proteins, leading to impaired blood clotting and prolonged bleeding after injury or trauma.
B. Excessive blood clotting is not a characteristic feature of hemophilia; rather, it is the opposite.
Hemophilia is characterized by a deficiency in clotting factors, which results in impaired clot formation.
C. Hemophilia does not typically result in increased platelet count. Platelets are involved in the initial stages of blood clotting, but hemophilia primarily affects clotting factor proteins.
D. Delayed wound healing is not a characteristic feature of hemophilia. Hemophilia primarily affects blood clotting, leading to prolonged bleeding, but it does not directly affect wound
healing processes.

A. The client's tongue is white. B. The client is nauseated. C. The client is jaundiced. D. The client is short of breath. E. The client reports feeling pain.

Correct Answer is ["C","E"]

Explanation

A. The client's tongue being white is not typically associated with sickle cell crisis but may indicate other issues such as oral thrush.
B. Nausea can be a symptom associated with many conditions and is not specific to sickle cell crisis.
C. Jaundice is a common manifestation of sickle cell crisis due to hemolysis of red blood cells, leading to an increase in bilirubin levels.
D. Shortness of breath may occur in sickle cell crisis if there is severe anemia or if the crisis is complicated by acute chest syndrome, but it is not a defining characteristic.
E. Pain is a hallmark symptom of sickle cell crisis, occurring due to vaso-occlusion and tissue ischemia resulting from the sickling of red blood cells.

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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

Which of the following is a characteristic feature of hemophilia?

Correct Answer is A

Explanation

A 30-year-old who is experiencing sickle cell crisis is admitted to the hospital. During the admission assessment, which findings can the nurse attribute to the client's blood disorder?

Correct Answer is ["C","E"]

Explanation

A nurse is reinforcing breast self-examination (BSE) teaching with a client who is menopausal. Which of the following statements by the client indicate an understanding of the teaching? (Select all that apply.)

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Which of the following can cause bone marrow suppression?

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A patient has received a medication that has caused significant hemolysis. Upon assessment, which of the following would the healthcare provider expect?

An 18-year-old male is taking Hydroxyurea for treatment of sickle cell anemia. Which options below indicate this medication is working successfully?