A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?
Uses a firm-bristled toothbrush
Increased intake of green, leafy vegetables
Drinks 2,500 mL of fluid per day
Wears a face mask around others
The Correct Answer is A
Choice A Reason:
Uses a firm-bristled toothbrush is correct. Clients with pernicious anemia often have neurological symptoms due to vitamin B12 deficiency. One of these neurological symptoms can be impaired proprioception, which is the body's ability to sense its position and movement in space. Using a firm-bristled toothbrush can increase the risk of injury because the client may have difficulty with fine motor skills and controlling the pressure applied to their teeth and gums, leading to potential gum injury or bleeding.
Choice B Reason:
Increased intake of green, leafy vegetables is incorrect. Increasing the intake of foods rich in vitamin B12, such as green, leafy vegetables, can be beneficial for clients with pernicious anemia, as it can help with vitamin B12 absorption and overall health.
Choice C Reason:
Drinks 2,500 mL of fluid per day is incorrect. Maintaining adequate hydration is essential for overall health and does not increase the risk of injury.
Choice D Reason:
Wears a face mask around others is incorrect. Wearing a face mask around others, especially in situations where respiratory precautions are necessary, is a preventive measure to reduce the risk of infection and does not inherently increase the risk of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Alcohol withdrawal can often lead to an increase in blood pressure. The autonomic nervous system becomes hyperactive during withdrawal, resulting in increased sympathetic activity, which can elevate blood pressure.
Constipation is not typically associated with alcohol withdrawal. However, chronic alcohol use can affect the gastrointestinal system and lead to digestive issues, including diarrhea or gastrointestinal bleeding.
Polyuria, which refers to excessive urination, is not a typical manifestation of alcohol withdrawal. However, alcohol use can affect fluid balance and lead to changes in urination patterns.
Bradycardia, or a slow heart rate, is not a common manifestation of alcohol withdrawal. Instead, tachycardia (an increased heart rate) is more commonly observed during withdrawal due to the hyperactivity of the autonomic nervous system.
Correct Answer is D
Explanation
Choice A Reason:
"I will no longer be able to eat nuts." While it's essential to be cautious about certain foods after a colostomy, avoiding nuts altogether may not be necessary. The client should discuss dietary restrictions with their healthcare provider or a registered dietitian.
Choice B Reason:
"I will empty the pouch every 2 to 3 hours." The frequency of pouch emptying can vary depending on the client's individual needs and the ostomy type. There's no fixed schedule for emptying the pouch, so this statement is not necessarily accurate.
Choice C Reason:
"I should expect my stool to be formed." The consistency of stool from a colostomy can vary depending on the location of the stoma and the type of colostomy. It may be formed or semi-formed, but it can also be more liquid or loose, depending on the circumstances. The client should
Choice D Reason:
"I will notify my doctor if the stoma starts to look purple." This statement reflects the client's awareness of the importance of monitoring the stoma's color and seeking medical attention if it appears discolored or compromised. A purple or dark-colored stoma can indicate inadequate blood supply, which is a concern that should be addressed promptly.
discuss stool consistency with their healthcare provider.
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