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 B
Explanation
Choice A Reason:
"Fidelity involves ensuring that we do no harm to the client.” This statement is more closely related to the ethical principle of nonmaleficence, which means "do no harm." Nonmaleficence focuses on avoiding harm and preventing any potential harm to the client.
Choice B Reason:
"Fidelity involves keeping promises made to clients." Fidelity is an ethical principle related to faithfulness, honesty, and keeping promises made to clients. It involves maintaining trust and being loyal to the client's best interests. This principle emphasizes the importance of nurses and healthcare providers honoring their commitments and obligations to clients, which helps build and maintain trust in the nurse-client relationship.
Choice C Reason:
"Fidelity involves making sure clients are able to make their own health care decisions. “This statement is more aligned with the ethical principle of autonomy, which emphasizes a person's right to make their own decisions about their healthcare. Autonomy relates to respecting a client's right to self-determination and informed consent.
Choice D Reason:
"Fidelity involves treating every client with the same level of respect." This statement is associated with the ethical principle of justice, which involves treating individuals fairly and equally and ensuring that they receive equitable care. It is about fairness and equality rather than the specific concept of keeping promises.
Correct Answer is B
Explanation
An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.
A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.
The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.
The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today