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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Performing breast self-examination (BSE) on the first day of each month provides a consistent schedule for the client to conduct the examination, making it easier to remember and ensuring regularity.
B. The first day of the menstrual cycle may not be the best time to perform BSE for all women, as breast tissue may be more tender or swollen during menstruation.
C. Seven days after the menstrual cycle begins may not be the best time for BSE, as hormonal fluctuations and breast changes may not yet have stabilized.
D. Performing BSE every month during ovulation is not necessary, as ovulation does not directly affect breast tissue changes that need to be monitored.
Correct Answer is B
Explanation
A. Presence of plethora is a common symptom of polycythemia vera and indicates increased blood volume but is not immediately life-threatening.
B. Calf swelling and pain could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate medical attention.
C. A platelet count of 450,000/microL is elevated but not as critical as the possibility of a DVT.
D. Hematocrit of 55% is high, which is expected in polycythemia vera, but it is not as immediately critical as the risk of thrombosis suggested by calf swelling and pain.
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