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 C
Explanation
The correct answer is choice C. Crohn's disease.
Choice A rationale:
Ulcerative colitis is a chronic inflammatory disease that primarily affects the colon and rectum, causing continuous areas of inflammation and ulcers. It does not involve any part of the GI tract from mouth to anus as stated in the question.
Choice B rationale:
Meckel's diverticulum is a congenital condition where a small pouch forms in the lower part of the small intestine. It is not characterized by a chronic inflammatory process involving various parts of the GI tract.
Choice C rationale:
Crohn's disease is a chronic inflammatory disorder that can affect any part of the gastrointestinal tract from mouth to anus. It commonly causes inflammation, ulceration, and narrowing of the affected segments of the intestines. This inflammation can lead to a range of symptoms including abdominal pain, diarrhea, and weight loss. The question accurately describes Crohn's disease.
Choice D rationale:
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain or discomfort and changes in bowel habits. It is not associated with chronic inflammatory processes or ulceration as seen in Crohn's disease.
Correct Answer is B
Explanation
The correct answers are choices B. Administer Benadryl, and D. Apply a cool compress.
Choice A rationale:
Placing an ace wrap on the bite is not recommended for a brown recluse spider bite. This action could potentially worsen the situation as it might trap venom in the area and increase the risk of necrosis.
Choice B rationale:
Administering Benadryl is a suitable action for alleviating pain and managing allergic reactions related to the bite. Benadryl (diphenhydramine) is an antihistamine that can help reduce itching and inflammation.
Choice C rationale:
Elevating the affected area might not provide significant pain relief for a brown recluse spider bite. Elevating is generally more effective for reducing swelling associated with injuries involving fluid accumulation, like sprains or strains.
Choice D rationale:
Applying a cool compress to the bite area can help alleviate pain and reduce inflammation. Cold therapy constricts blood vessels, which can reduce swelling and numb the area, providing relief.
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