Which of the following nursing diagnoses would typically NOT be associated with anemia?

Ineffective tissue perfusion.

Activity intolerance.

Fluid volume deficit.

Risk for decreased cardiac output.

Answer and Explanation

The Correct Answer is C

This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.

Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.

Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.

Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.

Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.

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Correct Answer is A

Explanation

This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.

This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.

Choice C is wrong because it is not an example of any level of prevention.

A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.

Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.

A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.

A. 3+ palpable pedal pulses below the affected injury site. B. Full range of motion at the site of injury. C. Sanguineous drainage at the site of injury. D. Localized warmth at the site of injury.

Correct Answer is D

Explanation

Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.

Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.

Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.

Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.

Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.

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Which of the following nursing diagnoses would typically NOT be associated with anemia?

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Naxlex Comprehensive Predictor Exams

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

Correct Answer is A

Explanation

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

Correct Answer is D

Explanation

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