A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?

Loss of hearing

Muscle wasting

Paresthesia

Changes in vision

Answer and Explanation

The Correct Answer is C

C. Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
A. Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.

D. While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.

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Correct Answer is A

Explanation

A. Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B. Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C. Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely

D. The specific amount can vary.

A. Avoid getting a flu vaccination. B. Limit fluids to 1.5 L per day. C. Limit alcohol intake to one drink per day. D. Avoid extremely hot or cold temperatures.

Correct Answer is D

Explanation

D. Extreme temperatures, both hot and cold, can trigger sickle cell crises in individuals with sickle cell disease. Cold temperatures can cause vasoconstriction and increase the risk of sickling of red blood cells, while hot temperatures can lead to dehydration. Therefore, clients with sickle cell disease should avoid exposure to extreme temperatures and take precautions to maintain a comfortable environment, especially during hot summer months and cold winter seasons.
A. Clients with sickle cell disease are at increased risk of developing complications from influenza (flu) infections. Therefore, it is highly recommended that clients with sickle cell disease receive an annual flu vaccination to reduce their risk of contracting the flu and its associated complications.
B. Hydration is crucial for individuals with sickle cell disease as it helps prevent dehydration and reduces the risk of sickling of red blood cells, which can trigger a sickle cell crisis.
C. Alcohol can exacerbate dehydration and increase the risk of vaso-occlusive crises in individuals with sickle cell disease.

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A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?

Nursing Test Bank

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