Nokea
An adult human patient has been diagnosed with anemia from iron deficiency anemia. What nursing diagnosis would be the most likely to be applicable to this patient's condition?
- A. Risk for deficient vascular volume related to low red blood cell production
- B. Risk for infection susceptibility related to low oxygen levels in tissue
- C. Anemia-related acute pain
- D. Fatigue from low oxygen transport capacity
Correct Answer: D
Rationale: Fatigue is the major assessment finding common to all forms of anemia. Anemia does not usually result in acute pain or fluid volume deficit. The patient may have an increased risk of infection due to impaired immune function, but fatigue is more likely.
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A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient?
- A. Packed red blood cells (PRBCs)
- B. Vitamin K
- C. Oral anticoagulants
- D. Heparin infusion
Correct Answer: A
Rationale: Patients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be ordered once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the patient's bleeding.
A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patient's plan of care?
- A. Risk for disuse syndrome related to ineffective peripheral circulation
- B. Functional urinary incontinence related to urethral occlusion
- C. Ineffective tissue perfusion related to thrombosis
- D. Ineffective thermoregulation related to hypothalamic dysfunction
Correct Answer: C
Rationale: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.
A group of nurses are learning about the high incidence of anemia prevalence of anemia among different populations. Which of the following patients would be the most likely to suffer from anemia a patient?
- A. A 50-year-old African American woman who is going through menopause
- B. An ?¾?????°?½?° ?? 80??80 elderly woman who has a diagnosis of heart failure
- C. A 48-year-old man who travels widely and has a high pressure job
- D. A 13-year-old girl who has just commenced menstruation
Correct Answer: B
Rationale: The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of anemia is compounded by the presence of heart disease. None of the other listed individuals exhibits high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia.
A nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?
- A. Take the iron with dairy products to enhance absorption.
- B. Increase the intake of vitamin E to enhance absorption.
- C. Iron will cause the stools to darken in color.
- D. Limit foods high in fiber due to the risk for diarrhea.
Correct Answer: C
Rationale: The nurse will inform the patient that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Patients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy.
The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crises, what measures should the nurse recommend?
- A. Using prophylactic antibiotics and performing meticulous hygiene
- B. Maximizing physical activity and taking OTC iron supplements
- C. Limiting psychosocial stress and eating a high-protein diet
- D. Avoiding cold temperatures and ensuring sufficient hydration
Correct Answer: D
Rationale: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.