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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Clotting is not directly related to the destruction of red blood cells.
B. Cyanosis refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation, which is not directly indicative of red blood cell destruction.
C. Jaundice is the yellowing of the skin and eyes caused by the buildup of bilirubin, a byproduct of the destruction of red blood cells, which is a common symptom of hemolytic anemia.
D. Bleeding is not a symptom associated with the destruction of red blood cells but rather a lack of clotting factors or platelets.
Correct Answer is B
Explanation
A. "With your recurrent history, one of these times the cyst will be malignant.": This response is not appropriate as it may cause unnecessary fear and is not supportive or informative.
B. "I appreciate your concern regarding another surgical procedure. Would you like to discuss your concerns?": This response validates the client's feelings and opens a dialogue for further discussion, allowing the client to express her concerns and receive appropriate information and support.
C. "The surgical procedure is minimal, and you will not have to be concerned after you learn the results.": This response dismisses the client's concerns and does not provide an opportunity for discussion.
D. "A prolonged ovarian abnormality should be evaluated thoroughly.": While this statement is true, it does not address the client's immediate concerns and does not encourage an open
discussion.
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