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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You will need to empty your bladder just before the exam.": Emptying the bladder before a pelvic examination allows for better visualization and manipulation of the pelvic organs.
B. "You should douche the evening prior to the examination.": Douching is not recommended before a Pap test as it can disrupt the natural flora of the vagina and may interfere with test results.
C. "You will be required to sign an informed consent prior to the exam.": Informed consent may be required for certain procedures but is not typically needed for a Pap test.
D. "You will be given light sedation before the examination starts.": Sedation is not typically used for a Pap test, which is a simple procedure that does not usually cause significant discomfort.
Correct Answer is C
Explanation
A. Herpes simplex virus can cause genital herpes, but it typically does not lead to pelvic inflammatory disease. Pelvic inflammatory disease is more commonly associated with untreated chlamydia or gonorrhea infections.
B. Syphilis during pregnancy can lead to various complications such as stillbirth, neonatal death, or congenital syphilis in the newborn, but low birth weight is not a typical complication.
C. Human papillomavirus (HPV) infection is a known risk factor for the development of cervical cancer. Certain high-risk strains of HPV can lead to precancerous changes in cervical cells,
which, if left untreated, may progress to cervical cancer.
D. Meningitis is not a typical complication of chlamydia in males. In males, untreated chlamydia can lead to complications such as epididymitis or infertility.
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