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 D

Explanation

Choice A Reason:

Irrigation of a wound with antibiotic solution is incorrect. Typically, irrigation of a wound with antibiotic solution doesn't require informed consent unless there are specific factors or risks involved that require it. This is usually considered a routine wound care procedure.

Choice B Reason:

Administration of an iron injection using Z-track technique is incorrect. Informed consent may not be required for this procedure if it's a routine and commonly performed nursing intervention. However, if there are specific concerns or potential risks (e.g., allergy to the medication), informed consent might be necessary.

Choice C Reason:

Insertion of a nasogastric tube is correct. Insertion of a nasogastric tube generally requires informed consent, especially if it's a non-emergent procedure. Informed consent is essential because there can be risks associated with the insertion, and the client should be informed and agree to it.

Choice D Reason:

Placement of a central venous catheter is correct. Placement of a central venous catheter definitely requires informed consent. It's a more invasive procedure that involves entering a major blood vessel, and there are specific risks and potential complications associated with it.

A. Improved respiratory function B. Reduced fat in the stools C. Improved absorption of vitamins B and C D. Decreased sodium excretion

Correct Answer is B

Explanation

Choice A Reason:

Improved respiratory function is incorrect. Pancrelipase primarily helps with the digestion and absorption of fats and fat-soluble vitamins. It does not directly impact respiratory function. Respiratory improvement in cystic fibrosis typically involves treatments such as airway clearance techniques, bronchodilators, and antibiotics to manage lung infections.

Choice B Reason:

Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy used to treat individuals with cystic fibrosis, a condition that affects the pancreas's ability to produce digestive enzymes. Cystic fibrosis leads to the malabsorption of nutrients, especially fats. Pancrelipase supplements these digestive enzymes and helps the child digest and absorb fat properly. As a result, one of the expected therapeutic effects of pancrelipase is a reduction in fat in the stools, as the enzymes aid in the digestion of dietary fats, leading to improved absorption of nutrients. This, in turn, can help address malnutrition and promote overall health in individuals with cystic fibrosis.

Choice C Reason:

Improved absorption of vitamins B and C is incorrect. While pancrelipase can help with the absorption of fat-soluble vitamins (A, D, E, and K), it does not directly affect the absorption of vitamins B and C, which are water-soluble vitamins. Cystic fibrosis primarily affects the absorption of fat-soluble vitamins due to impaired fat digestion.

Choice D Reason:

Decreased sodium excretion is incorrect. Cystic fibrosis is associated with excessive loss of salt (sodium chloride) in sweat. Pancrelipase does not directly affect sodium excretion. Treatment for managing sodium loss typically involves salt supplementation and ensuring proper hydration.

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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 reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is D

Explanation

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is B

Explanation

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