The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

Activity intolerance related to tissue hypoxia

Ineffective airway clearance related to dyspnea.

Risk for infection related to reduction in white blood cells (WBCs)

Chronic pain related to bone marrow dysfunction

Answer and Explanation

The Correct Answer is A

A. Activity intolerance related to tissue hypoxia: Pernicious anemia leads to a decrease in the body’s ability to carry oxygen due to a lack of intrinsic factor and subsequent vitamin B12 deficiency, resulting in tissue hypoxia. This can cause fatigue and activity intolerance as the body struggles to meet its oxygen demands.

B. Ineffective airway clearance related to dyspnea: Dyspnea may occur, but ineffective airway clearance is not directly related to pernicious anemia, as this condition primarily affects oxygen transport, not the airway.

C. Risk for infection related to reduction in white blood cells (WBCs): Pernicious anemia primarily affects red blood cells due to vitamin B12 deficiency; it does not typically lead to a reduction in white blood cells.

D. Chronic pain related to bone marrow dysfunction: While bone marrow may be affected in some anemias, chronic pain is not a typical symptom of pernicious anemia, and bone marrow dysfunction is not usually present.

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Correct Answer is C

Explanation

A. Hip: While “hip” can sometimes colloquially refer to the iliac crest, it is not commonly used to describe the specific site for aspiration outside of the iliac crest.

B. Cervical spine: The cervical spine is not a site used for bone marrow aspiration due to its inaccessibility and proximity to critical structures.

C. Sternum: The sternum is a common site for bone marrow aspiration in adults as it provides direct access to the marrow.

D. Humerus: The humerus is generally not used for bone marrow aspirations as it does not provide as accessible or large an area for aspiration.

A. Ineffective airway clearance related to swelling of the lymph nodes B. Ineffective tissue perfusion related to vascular occlusion C. Risk for injury related to compromised bone integrity D. Risk for deficit fluid volume related to a bleeding disorder

Correct Answer is C

Explanation

A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.

B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.

C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.

D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.

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The nurse is assisting in the development of a care plan for a patient with pernicious anemia. Which of the following would be the most common nursing diagnosis with this medical condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should tell the client that, in addition to the iliac crest, a common site for this procedure is which of the following?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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