Health Promotion and Maintenance
78. A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What are the priority nursing diagnoses related to this child's care? Select all that apply.
Health Promotion and Maintenance
78. A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What are the priority nursing diagnoses related to this child's care? Select all that apply.
. Risk for infection.
. Impaired elimination.
. Risk for injury.
. Disturbed body image.
. Chronic pain.
. Activity intolerance.
Test-Taking Tip
Risk for infection (Answer 1) and injury (Answer 3) and circulation (Answer 6) are high priorities on Maslow's hierarchy of needs–followed by self-esteem related to body image (Answer 4).
Content Area: Child Health, Hematology; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Hemodynamics
Health Promotion and Maintenance
. . . .
Answer 1 is correct because children with beta-thalassemia are at increased risk for infection due to the impaired oxygen-carrying capacity of their blood. Answer 2 is incorrect because elimination is not a problem with beta-thalassemia. Answer 3 is correct because these children are at risk for injury from an increased destruction of red blood cells. As red blood cells die, iron is released with deposits in the liver and spleen, enlarging these organs and impairing their function while also causing vomiting from abdominal pressure. Answer 4 is correct because these children may experience bone deformities, growth retardation, and delayed maturation of the sexual organs. These symptoms (e.g., broad forehead, short stature, immature appearance) may be troubling for an adolescent, whose main concern is to fit in with the peer group. Answer 5 is incorrect because these children do not experience chronic pain. Answer 6 is correct because chronic hypoxia results from the production of abnormal red blood cells. If the body does not have sufficient red blood cell production, oxygen is not supplied to the tissues adequately, leading to activity intolerance and fatigue.