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","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.
Correct Answer is A
Explanation
A. Abnormal vaginal bleeding. Abnormal vaginal bleeding, especially postmenopausal bleeding, is the most common symptom reported by clients being evaluated for endometrial cancer.
B. Recurrent urinary tract infections. This is not a common symptom of endometrial cancer.
C. Hot flashes. Hot flashes are typically associated with menopause and hormone changes, not endometrial cancer.
D. Blood in the stool. Blood in the stool is more commonly associated with gastrointestinal issues or colorectal cancer, not endometrial cancer.
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