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 B

Explanation

A. Report fever to MD ASAP: While fever in any immunocompromised patient should be reported, it does not directly address precautions related to low platelet counts and bleeding risks.

B. Use a soft toothbrush with oral care: With a low platelet count, the patient is at risk for bleeding. Using a soft toothbrush minimizes the risk of gum injury and bleeding, a critical safety measure for thrombocytopenic patients.

C. Drink hot liquids TID: Hot liquids are not recommended as they may cause mouth or esophageal burns, increasing bleeding risk if the mucosa is damaged. Tepid or cold fluids are safer.

D. Recommend straight edge razor for shaving: Patients with low platelets should use an electric razor to avoid cuts, as any bleeding is harder to control in thrombocytopenic individuals.

A. Results indicate the presence of Reed Sternberg cells B. The patient is cyanotic C. The patient is complaining of excessive thirst and hunger D. Results indicate the presence of the Philadelphia chromosome

Correct Answer is A

Explanation

A. Results indicate the presence of Reed Sternberg cells: Reed-Sternberg cells are a defining characteristic of Hodgkin disease, a type of lymphoma. Their presence in biopsy samples confirms the diagnosis, distinguishing Hodgkin disease from other types of lymphomas and leukemias.

B. The patient is cyanotic: Cyanosis, or bluish skin discoloration due to low oxygen levels, is not a common sign of Hodgkin disease. It may occur in advanced disease due to respiratory compromise but is not a defining characteristic.

C. The patient is complaining of excessive thirst and hunger: Excessive thirst and hunger are more characteristic of diabetes mellitus, not Hodgkin disease. These symptoms are unrelated to the lymphatic involvement seen in Hodgkin disease.

D. Results indicate the presence of the Philadelphia chromosome: The Philadelphia chromosome is a genetic abnormality associated with chronic myelogenous leukemia (CML), not Hodgkin disease. Its presence suggests a different hematologic malignancy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a platelet count of <20,000/mm3 (150,000-400000). Which of the following precautions should the nurse take in providing care for this patient?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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