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 D
Explanation
A. Syphilis can indeed affect many areas of the body, including the brain and heart, but this statement does not specifically address primary syphilis, which is characterized by the appearance of a painless sore (chancre) at the site of infection.
B. Syphilis does not typically resolve on its own. Without treatment, the infection can progress to more severe stages with potentially serious complications.
C. Syphilis is caused by a bacterial infection (Treponema pallidum) and is treated with antibiotics such as penicillin. Antiviral medications are not effective against bacterial infections like syphilis.
D. This statement is accurate and important for the prevention of syphilis transmission. Syphilis can be transmitted through vaginal, anal, or oral sex, but the risk of transmission is lower during oral sex compared to vaginal or anal intercourse.
Correct Answer is D
Explanation
A. Multiple hospitalizations for COPD are not a direct contraindication for HRT, although respiratory health should be monitored.
B. Concurrent treatment for GERD is not a contraindication for HRT.
C. History of dermatitis does not contraindicate the use of HRT.
D. History of breast cancer is a significant contraindication for HRT due to the potential for hormone therapy to stimulate the growth of hormone-sensitive cancer cells.
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