What is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia?
Risk for injury related to depressed sensorium.
Decreased cardiac output related to abnormal hemoglobin.
Activity intolerance related to generalized weakness.
Risk for Injury related to dehydration and abnormal hemoglobin.
The Correct Answer is C
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Slowed growth.
Choice A rationale:
Slowed growth is a potential risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are a cornerstone of asthma management due to their anti-inflammatory effects on the airways, but they can have systemic effects when absorbed in larger amounts. Prolonged use of these steroids can potentially lead to growth suppression in children by affecting the normal growth and development of bones and other tissues.
Choice B rationale:
Osteoporosis is not the primary concern in children taking inhaled steroids. While long-term use of high-dose systemic steroids can lead to bone loss and osteoporosis in adults, the risk of osteoporosis is much lower in children receiving inhaled steroids for asthma management. Inhaled steroids have a lower systemic absorption, reducing the risk of significant bone density reduction in children.
Choice C rationale:
Cushing's syndrome is a condition caused by prolonged exposure to high levels of cortisol, often due to excessive use of systemic steroids. Inhaled steroids, especially at recommended doses, have a lower likelihood of causing Cushing's syndrome compared to systemic steroids. The systemic absorption of inhaled steroids is limited, minimizing the risk of this syndrome.
Choice D rationale:
Cough is not the primary increased risk associated with long-term use of inhaled steroids in children with asthma. Inhaled steroids are actually used to help control and prevent asthma symptoms, including cough. They work by reducing inflammation in the airways, which helps alleviate symptoms like coughing, wheezing, and shortness of breath.
Correct Answer is C
Explanation
The correct answer is Choice C: Measure abdominal girth.
Choice A rationale:
Taking vital signs, including blood pressure, is important in assessing the overall health status of a child, but it might not provide specific information about a probable intussusception. Blood pressure is not typically affected in a way that directly relates to intussusception.
Choice B rationale:
Auscultating for bowel sounds is an important assessment technique in various gastrointestinal conditions, but it may not be the most appropriate immediate action when dealing with a probable intussusception. While bowel sounds might be diminished or absent in intussusception, the priority should be on assessing other signs and symptoms.
Choice C rationale:
Measuring abdominal girth is an essential nursing action when a child with a probable intussusception has a normal, brown stool. Intussusception is the telescoping of one segment of the intestine into another, often leading to bowel obstruction. Abdominal distension or girth measurement can provide valuable information about the progression of the condition and potential obstruction.
Choice D rationale:
Notifying the practitioner is an important step, but it might not be the most immediate action required. Assessing and monitoring the child's condition should be the initial response to gather more information before notifying the practitioner.
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