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 C

Explanation

A. Presence of Bence-Jones protein in the urine is indicative of multiple myeloma, but hypercalcemia is a more urgent issue to address.
B. Severe back pain is common in multiple myeloma due to bone involvement, but it is not as immediately life-threatening as hypercalcemia.
C. Elevated serum calcium levels (hypercalcemia) are a common complication of multiple myeloma and can lead to various complications, including kidney damage, altered mental status, and cardiac arrhythmias. Therefore, it is crucial to report significantly elevated serum calcium levels promptly to the health care provider for appropriate management.
D. Patient reports no stool for 5 days may indicate constipation, which is important to address but is not as urgent as hypercalcemia in the context of multiple myeloma.

A. Vaginal bleeding B. Slight decrease in basal body temperature C. Breast tenderness D. Decreased sex drive E. Lower abdominal pain/ cramping

Correct Answer is E

Explanation

A. Vaginal bleeding is not a typical sign of ovulation. Vaginal bleeding occurs during menstruation, which is distinct from ovulation.
B. A slight decrease in basal body temperature may occur before ovulation, not during ovulation itself.
C. Breast tenderness can occur due to hormonal changes during the menstrual cycle, but it is not a direct indicator of ovulation.
D. Decreased sex drive is not a typical symptom of ovulation. In fact, some women may experience an increase in sex drive around ovulation.

E. Lower abdominal pain/cramping, also known as mittelschmerz, is a common symptom of ovulation. It typically occurs on one side of the lower abdomen and can help indicate the timing of ovulation.

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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:

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Naxlex Comprehensive Predictor Exams

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?

Correct Answer is C

Explanation

The nurse is performing an assessment on a client who asks how she might recognize when she is ovulating. The nurse should explain that which occurs at ovulation?

Correct Answer is E

Explanation

A nurse is reinforcing teaching about the frequency of breast self-examination (BSE) with a young adult client. Which of the following statements by the client indicates an understanding of the teaching?

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Which of the following can cause bone marrow suppression?

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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:

Blood loss is a major cause of iron deficiency in adults. Some sources of chronic blood loss in adults are all except:

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