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
Choice A Reason:
Hypoglycemia (low blood sugar) is not a common adverse effect of atorvastatin.
Choice B Reason:
Daytime drowsiness is not a typical side effect of statin medications and is more commonly associated with other types of medications, such as sedatives or sleep aids.
Choice C Reason:
Muscle pain is correct. The nurse should instruct the client to monitor and report muscle pain (myalgia) to the healthcare provider when taking atorvastatin. Myalgia is a potential adverse effect of statin medications, and in rare cases, it can progress to a more serious condition called rhabdomyolysis, which involves muscle breakdown and can lead to kidney damage. Therefore, any new or unexplained muscle pain, tenderness, or weakness should be reported promptly to the healthcare provider for evaluation.
Choice D Reason:
Palpitations (rapid or irregular heartbeats) are not commonly associated with atorvastatin use. If a client experiences palpitations, it may be related to other factors or conditions and should be evaluated separately.
Correct Answer is A
Explanation
Choice A Reason:
Client isolates themselves from their family and friends. Isolating oneself from family and friends is an indication that the client is experiencing a crisis. Social withdrawal and isolation can be common responses to severe anxiety or a crisis situation. It suggests that the client is having difficulty coping with their anxiety or the stressor, and they may benefit from intervention and support.
Choice B Reason:
Reporting intermittent depressed mood may be indicative of a mood disorder but does not necessarily indicate a crisis.
Choice C Reason:
Reporting a decreased appetite can be a symptom of anxiety, but it is not specific to a crisis situation.
Choice D Reason:
Expressing an inability to experience pleasure is a symptom often associated with depression but does not provide specific information about the presence of a crisis.
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