The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

Activity intolerance related to tissue hypoxia

Ineffective airway clearance related to dyspnea.

Risk for infection related to reduction in white blood cells (WBCs)

Chronic pain related to bone marrow dysfunction

Answer and Explanation

The Correct Answer is A

A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.

B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.

C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.

D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.

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Correct Answer is C

Explanation

A. Red blood cells (RBCs) 5.0 million/mm³ (F 4.2–5.4; M 4.7–6.1): This RBC count is within normal limits and does not indicate a concern related to thrombocytopenia.

B. Hemoglobin 14.5 g/100 mL (F 12–16; M 14–18): Hemoglobin is within normal limits and is not an immediate concern for a patient with ITP, as thrombocytopenia primarily affects platelets, not hemoglobin levels.

C. Platelets 50,000/mm³ (150,000–400,000): A platelet count of 50,000/mm³ is significantly below the normal range and poses a risk for bleeding, which is the primary concern in ITP (immune thrombocytopenic purpura).

D. White blood cells (WBCs) 7,400/mm³ (5,000–10,000): The WBC count is normal and not directly related to thrombocytopenia in ITP, which specifically affects platelets.

A. Malformed RBCs B. A deficiency in vitamin B12 C. An abundance of immature RBCS D. Destruction of RBCs

Correct Answer is D

Explanation

A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.

B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.

C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.

D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.

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The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

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Naxlex Comprehensive Predictor Exams

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