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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:

A client who has a femur fracture and reports numbness of the toes. In the given scenario, the nurse should prioritize seeing the client with a femur fracture who reports numbness of the toes. Numbness in the toes may indicate compromised circulation or nerve damage, which can be a serious complication of a femur fracture. Addressing this issue promptly is crucial to prevent further complications.

Choice B Reason:

A client with cirrhosis and severe pruritus, while uncomfortable, does not require immediate intervention in the same way that a potential circulation issue does.

Choice C Reason:

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable and not in immediate distress. The nurse can see this client after addressing the more urgent situation.

Choice D Reason:

A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be monitored closely for signs of bleeding, but the issue is not as urgent as the potential nerve or circulation problem in the client with a femur fracture and numbness of the toes.

A. "I will discontinue music therapy when my husband is no longer responsive." B. "Music will distract my husband's awareness of the pain." C. "Playing music will increase my husband's alertness." D. "My husband won't need medication for breakthrough pain while using music therapy."

Correct Answer is B

Explanation

Choice A Reason:

Discontinuing music therapy when the client is no longer responsive is not necessary. Music therapy can continue to provide comfort and support even if the client is not responsive.

Choice B Reason:

"Music will distract my husband's awareness of the pain." This statement indicates an understanding of the potential benefits of music therapy for pain management. Music therapy can help distract individuals from their pain, reduce anxiety and stress, and enhance relaxation. It may not eliminate pain entirely but can provide a valuable complementary approach to pain management in hospice care.

Choice C Reason:

Playing music is not typically used to increase alertness in the context of pain management. Instead, it is often used to promote relaxation and reduce pain-related distress.

Choice D Reason:

Music therapy is not a replacement for medication in managing pain, especially breakthrough pain. Medication and music therapy can be used together as part of a comprehensive pain management plan in hospice care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?

Correct Answer is B

Explanation

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