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 B
Explanation
The correct answer is choice B. Ask the adolescent, "Why did you come here today?".
Choice A rationale:
Using the adolescent's own words in correct medical terminology to determine the problem is essential for accurate documentation, but it might not be the initial step in determining the chief complaint. The approach in choice B provides an opportunity for the adolescent to express their primary concern in their own terms.
Choice B rationale:
Asking the adolescent, "Why did you come here today?" allows them to voice their main reason for the visit in their own words. This approach respects their autonomy and encourages open communication. It also helps to identify the primary issue from the adolescent's perspective.
Choice C rationale:
While asking for a detailed listing of symptoms is important for a comprehensive health history, it might not be the best way to initially determine the chief complaint. This approach could potentially overwhelm the patient and miss the opportunity for them to express their primary concern.
Choice D rationale:
Interviewing the parent away from the adolescent might be necessary in certain situations, but it is not the best method for determining the adolescent's chief complaint. The adolescent's input is crucial for understanding their own health concerns and developing a patient-centered approach.
Correct Answer is B
Explanation
The correct answer is choice B. It has a harsh, barky cough.
Choice A rationale:
Spasmodic croup is characterized by sudden-onset symptoms, including a barking cough, but it is not typically associated with a high fever. The barky cough is caused by inflammation and narrowing of the upper airways, leading to a distinct sound when the child coughs.
Choice B rationale:
A harsh, barky cough is a hallmark symptom of spasmodic croup. It is caused by the swelling of the vocal cords and the upper airway, resulting in the characteristic sound. This type of croup is often triggered by viral infections and is usually not bacterial in nature.
Choice C rationale:
Spasmodic croup is usually of viral origin rather than bacterial. Bacterial infections may lead to other respiratory conditions, but they are not a distinguishing feature of spasmodic croup.
Choice D rationale:
Wheezing is not a typical manifestation of spasmodic croup. Wheezing is often associated with lower airway conditions such as asthma, while croup primarily affects the upper airways and vocal cords, leading to the barking cough.
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