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 C
Explanation
c. Roasted salmon
The nurse should include roasted salmon on the tray for the client who follows a kosher diet.
Kosher dietary laws prohibit the consumption of shellfish such as clams and shrimp, as well as pork products like pulled pork sandwiches. Roasted salmon, on the other hand, is a permissible food item in a kosher diet.
It's important for the nurse to be aware of the client's dietary restrictions and preferences to ensure that they receive appropriate and culturally sensitive care.
Correct Answer is A
Explanation
Choice A Reason:
Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.
Choice B Reason:
Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.
Choice C Reason:
Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.
Choice D Reason:
Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.
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