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 D
Explanation
A. Skin color: While changes in skin color can occur in hemochromatosis due to excess iron deposition, it is not the most important parameter to monitor for the effectiveness of deferoxamine.
B. Liver function: Liver function tests can be abnormal in hemochromatosis due to iron overload, but monitoring liver function alone may not adequately assess the effectiveness of deferoxamine in reducing iron levels.
C. Hematocrit: Hematocrit measures the proportion of blood that is made up of red blood cells and may be elevated in hemochromatosis, but it is not the primary parameter to monitor the effectiveness of deferoxamine.
D. Serum iron level: Serum iron level is the most direct indicator of iron overload and the effectiveness of deferoxamine in chelating and removing excess iron from the body.
Correct Answer is B
Explanation
A. Radiation exposure: Radiation exposure can cause aplastic anemia, but if the cause is unknown, it is less likely to be due to a specific and identifiable event like radiation exposure.
B. An autoimmune disorder: When the cause of aplastic anemia cannot be diagnosed, it is often attributed to an autoimmune disorder where the body attacks its own bone marrow cells.
C. Chemotherapy drugs: Chemotherapy drugs can cause aplastic anemia, but this cause would typically be known based on the patient's medical history.
D. Toxins: Toxins can cause aplastic anemia, but like chemotherapy drugs and radiation, this cause would generally be identifiable.
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