For a client diagnosed with folic acid deficiency anemia who is experiencing activity intolerance, what should the nurse include in the plan of care?

Provide a quiet atmosphere for undisturbed sleep.

Cluster activities in the morning when well-rested.

Identify ways to conserve energy when performing activities.

Recommend small frequent iron-rich meals.

Answer and Explanation

The Correct Answer is C

Choice A Reason
Providing a quiet atmosphere for undisturbed sleep is beneficial for all patients, especially those recovering from illness. However, it does not directly address the issue of activity intolerance. Adequate rest is important, but the primary concern with activity intolerance is managing energy levels during waking hours to improve the patient's ability to engage in activities.

Choice B Reason
Clustering activities in the morning may seem like a good strategy when the patient is well-rested. However, this could lead to rapid depletion of energy reserves and exacerbate activity intolerance. It is more effective to spread activities throughout the day to manage energy levels better.

Choice C Reason
Identifying ways to conserve energy is a key intervention for managing activity intolerance. This can include teaching the patient energy-conservation techniques, such as sitting while showering or dressing, taking frequent breaks, and prioritizing tasks. This approach helps patients with folic acid deficiency anemia to participate in activities without excessive fatigue.

Choice D Reason
While nutrition is important in the management of anemia, recommending small frequent iron-rich meals does not directly address activity intolerance. Folic acid deficiency anemia requires dietary intake of folate-rich foods or supplements. Iron is important, but the focus for folic acid deficiency should be on folate.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

Choice A Reason:
A glucose level of at least 600 mg/dL is more indicative of hyperglycemic hyperosmolar state (HHS) rather than diabetic ketoacidosis (DKA). While both conditions involve high blood sugar levels, DKA is typically characterized by blood glucose levels that are high but not as extreme as those seen in HHS1.

Choice B Reason:
A fruity, acetone smell to the breath is a classic sign of DKA. This odor is due to the presence of ketones, particularly acetone, which is exhaled. It’s one of the key clinical manifestations that can help in the diagnosis of DKA.

Choice C Reason:
The absence of ketones in the urine would not be consistent with a diagnosis of DKA. One of the hallmarks of DKA is the presence of ketones in the urine, resulting from the breakdown of fats due to a lack of insulin.

Choice D Reason:
Polyuria (excessive urination) and polydipsia (excessive thirst) are symptoms of DKA. They occur as the body tries to eliminate excess glucose through the urine, which can lead to dehydration and the need to drink more fluids.

Choice E Reason:
Rapid, deep breathing, also known as Kussmaul respiration, is a compensatory mechanism for the acidosis seen in DKA. The body attempts to correct the acidic pH by exhaling more carbon dioxide.

A. Abdominal distention B. Hypoactive bowel sounds C. Diarrhea D. Fever

Correct Answer is A

Explanation

Choice A Reason:
Abdominal distention is a common finding in large bowel obstruction due to the accumulation of intestinal contents, gas, and fluid proximal to the obstruction site. This can lead to a visibly swollen abdomen and is often accompanied by discomfort or pain.

Choice B Reason:
Hypoactive bowel sounds are expected in large bowel obstruction as the peristaltic activity decreases below the point of obstruction. Initially, bowel sounds may be high-pitched or tinkling due to the intestine's attempt to move contents past the obstruction, but as the condition progresses, the sounds become less frequent or even absent.

Choice C Reason:
Diarrhea is not typically associated with large bowel obstruction. In fact, constipation or cessation of stool is a more common symptom. If diarrhea occurs, it may be due to a partial obstruction or the presence of liquid stool that can pass around the blockage.

Choice D Reason:
Fever may indicate a complication of large bowel obstruction, such as ischemia or perforation, leading to infection and inflammation. However, fever is not a primary symptom of uncomplicated large bowel obstruction and should prompt immediate further investigation.

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For a client diagnosed with folic acid deficiency anemia who is experiencing activity intolerance, what should the nurse include in the plan of care?

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