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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A: Surgical removal of the affected section of bowel.
Choice A rationale:
Surgical removal of the affected section of bowel is the primary therapeutic management for most children with Hirschsprung's disease. Hirschsprung's disease is a congenital condition where there is a lack of nerve cells in a segment of the colon, leading to obstruction and dilation of the bowel. Surgical resection of the affected segment and reconnection of healthy bowel portions is the standard treatment to alleviate the obstruction and restore normal bowel function.
Choice B rationale:
Daily enemas might be used in some cases to manage symptoms temporarily, but they are not the primary therapeutic management for Hirschsprung's disease. Surgery is the mainstay of treatment.
Choice C rationale:
Permanent colostomy might be considered if the affected portion of bowel is extensive and cannot be safely reconnected after resection, but it's not the primary option for most children with Hirschsprung's disease.
Choice D rationale:
A low-fiber diet is not a therapeutic management for Hirschsprung's disease. Surgical intervention is necessary to address the underlying cause of obstruction, and diet modifications alone wouldn't resolve the condition.
Correct Answer is A
Explanation
The correct answer is choice A. Meconium ileus.
Choice A rationale:
Meconium ileus. This is the earliest recognizable clinical manifestation of cystic fibrosis (CF). Meconium ileus refers to the blockage of the small intestine by thick, sticky meconium, the earliest stool of a newborn. It occurs in the first 24-48 hours of life and can be a sign of underlying cystic fibrosis.
Choice B rationale:
Foul-smelling, frothy, greasy stools. Foul-smelling, frothy, greasy stools are characteristic of malabsorption, which can occur in cystic fibrosis. However, this manifestation typically appears after meconium ileus and is not the earliest recognizable clinical sign.
Choice C rationale:
History of poor intestinal absorption. While poor intestinal absorption is a common consequence of cystic fibrosis, it is not one of the earliest recognizable clinical manifestations. Meconium ileus takes precedence as the primary early sign.
Choice D rationale:
Recurrent pneumonia and lung infections. Recurrent pneumonia and lung infections are common in later stages of cystic fibrosis due to the buildup of thick mucus in the respiratory tract. However, they are not among the earliest recognizable clinical manifestations of the disease. Meconium ileus is the earliest indicator in this context.
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