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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Vitamin C is not known to cause bone marrow suppression. In fact, it is essential for the proper function of the immune system and the production of collagen.
B. Physical exercise does not cause bone marrow suppression. Regular exercise can have positive effects on bone health and overall well-being.
C. Chemotherapy, which is used to treat cancer, can cause bone marrow suppression as a side effect. It affects rapidly dividing cells, including those in the bone marrow responsible for producing blood cells.
D. Some antibiotics, such as certain types of penicillins and sulfonamides, can rarely cause bone marrow suppression as a side effect. However, this is not a common effect of all antibiotics.
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