In helping prepare a nursing care plan for a 90-pound, 82-year-old woman with iron-deficiency anemia with a hemoglobin of 8.2, the nurse agrees that the most appropriate nursing diagnosis would be:

Activity intolerance, related to fatigue.

Disturbed body image, related to weight loss.

Anxiety, related to unfamiliar hospital environment.

Impaired tissue integrity, related to immobility.

Answer and Explanation

The Correct Answer is A

A.   Given the low hemoglobin level and weight, the patient is likely experiencing fatigue due to decreased oxygen-carrying capacity of the blood, leading to activity intolerance.
B.   While weight loss may contribute to body image disturbance, it is not the primary concern for a patient with iron-deficiency anemia and low hemoglobin levels.
C.   Anxiety related to the hospital environment may be present, but it is not the most appropriate nursing diagnosis based on the patient's clinical presentation and laboratory findings.
D.   Impaired tissue integrity related to immobility is not the most appropriate nursing diagnosis for a patient with iron-deficiency anemia. This diagnosis is more commonly associated with pressure ulcers or skin breakdown in patients who are immobile for extended periods, which is not described in this scenario.

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Correct Answer is A

Explanation

A. Prolonged bleeding or easy bruising is a characteristic feature of hemophilia, a genetic
disorder characterized by deficient or defective blood clotting proteins, leading to impaired blood clotting and prolonged bleeding after injury or trauma.
B. Excessive blood clotting is not a characteristic feature of hemophilia; rather, it is the opposite.
Hemophilia is characterized by a deficiency in clotting factors, which results in impaired clot formation.
C. Hemophilia does not typically result in increased platelet count. Platelets are involved in the initial stages of blood clotting, but hemophilia primarily affects clotting factor proteins.
D. Delayed wound healing is not a characteristic feature of hemophilia. Hemophilia primarily affects blood clotting, leading to prolonged bleeding, but it does not directly affect wound
healing processes.

A. "I will make sure to feel for changes in my underarm area." B. "Since I no longer have periods, I can do the exam at any time of the month." C. "It is important to press my breasts firmly to detect any lumps." D. "I can stand in the shower to perform the examination." E. "I will use my fingertips to check my breasts."

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

Explanation

A. Feeling for changes in the underarm area is important as breast tissue extends into this region and lumps can form there.
B. Since menopausal women do not have periods, they can perform BSE at any consistent time each month to help remember to do it regularly.
C. Pressing the breasts too firmly could cause discomfort and is not necessary for detecting lumps.
D. Performing BSE in the shower is effective because the soapy water allows the fingers to move smoothly over the skin.
E. Using fingertips is the proper technique for checking breasts, as it allows for more sensitivity in detecting changes in the breast tissue.

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In helping prepare a nursing care plan for a 90-pound, 82-year-old woman with iron-deficiency anemia with a hemoglobin of 8.2, the nurse agrees that the most appropriate nursing diagnosis would be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a characteristic feature of hemophilia?

Correct Answer is A

Explanation

A nurse is reinforcing breast self-examination (BSE) teaching with a client who is menopausal. Which of the following statements by the client indicate an understanding of the teaching? (Select all that apply.)

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

Explanation

A nurse is collecting data from a male client who has been exposed to syphilis and has a genital chancre. Which of the following prescriptions should the nurse anticipate when notifying the provider of these findings?

What is the priority nursing diagnosis for a client with inadequate production of platelets?

A patient is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching?

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

A nurse is reinforcing teaching to a client who is to undergo a breast biopsy by needle aspiration. Which of the following statements should the nurse make?

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

A nurse is reinforcing teaching to a client who has endometriosis. Which of the following statements should the nurse include in the teaching?

A nurse manager in a health clinic is discussing complications associated with sexually transmitted infections (STIs) with a newly licensed nurse. Which of the following statements should be included in the discussion?