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
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. Intense abdominal pain: While abdominal pain may occur in some conditions related to anemia, it is not a typical finding in anemia due to blood loss.
B. Respiratory depression: Respiratory depression is not commonly associated with anemia and would more likely indicate issues with central nervous system depression or drug side effects.
C. Dyspnea on exertion: Dyspnea on exertion is common in clients with anemia because of the decreased oxygen-carrying capacity of the blood, leading to tissue hypoxia. Anemia results in decreased hemoglobin levels, reducing the body’s ability to deliver adequate oxygen, particularly during physical activity.
D. Bradycardia: Anemia typically causes tachycardia (increased heart rate) rather than bradycardia, as the body compensates for low oxygen levels by increasing cardiac output.
Correct Answer is B
Explanation
A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.
B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.
C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.
D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.