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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Related Questions
Correct Answer is B
Explanation
A. Hemophilia B results from a deficiency in clotting factor VIII. Hemophilia B results from a deficiency in clotting factor IX. Hemophilia A results from a deficiency in clotting factor VIII.
B. Males inherit hemophilia from their mothers. Hemophilia is an X-linked recessive disorder, meaning males inherit the defective gene from their carrier mothers.
C. Females inherit hemophilia from their fathers. Females can be carriers if they inherit the
defective gene from their mother, but they generally do not inherit the disease itself from their fathers due to the X-linked recessive inheritance pattern.
D. Hemophilia is a Y linked disorder. Hemophilia is not Y-linked; it is an X-linked recessive disorder.
Correct Answer is C
Explanation
A. Gastrointestinal bleeding is a common source of chronic blood loss leading to iron deficiency anemia.
B. Peptic ulcers can cause chronic gastrointestinal bleeding, contributing to iron deficiency.
C. Loss of intrinsic factor leads to vitamin B12 deficiency and pernicious anemia, not iron deficiency.
D. Genitourinary bleeding is another potential source of chronic blood loss that can result in iron deficiency anemia.
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