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. "My doctor will perform pelvic exams to detect for ovarian cancer.": Pelvic exams can help detect ovarian cancer or abnormalities in the pelvic region, although they are not always definitive.
B. "I will develop ovarian cancer If I have the BRCA1 gene.": While having the BRCA1 gene mutation increases the risk of ovarian cancer, not everyone with this gene mutation will develop the disease.
C. "I will have regular Pap tests to monitor for ovarian cancer.": Pap tests are used to screen for cervical cancer, not ovarian cancer.
D. "A decreased CA125 level places me at greater risk for ovarian cancer.": An elevated CA125 level is associated with ovarian cancer, not a decreased level.
Correct Answer is ["A","B","G"]
Explanation
A. Severe pain is a hallmark manifestation of a sickle cell crisis due to vaso-occlusion and tissue ischemia.
B. Fever can occur during a sickle cell crisis, often indicating an underlying infection or inflammatory response.
C. Normal blood counts are not typical during a sickle cell crisis; patients often exhibit anemia, leukocytosis, and thrombocytosis.
D. Clear urine is not a common manifestation of a sickle cell crisis; hematuria or dark-colored urine may occur due to hemolysis or kidney damage.
E. Increased energy levels are not typical during a sickle cell crisis; patients often experience fatigue and malaise.
F. Normal oxygen saturation levels may occur in some patients during a sickle cell crisis, but it is not a consistent finding.
G. Jaundice is common in sickle cell crisis due to hemolysis of red blood cells, leading to an increase in bilirubin levels.
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