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.
Prescribed vitamin B12 IM.
Prescribed epoetin IV.
Sleeps 8 to 10 hr per night.
The Correct Answer is A
Choice A rationale:
Using a firm-bristled toothbrush can increase the risk of gum injury or bleeding, especially in individuals with pernicious anemia who may have fragile gums due to vitamin B12 deficiency. This choice is correct because it identifies a risk factor for injury.
Choice B rationale:
Prescribing vitamin B12 intramuscularly (IM) is the appropriate treatment for pernicious anemia and does not increase the client's risk of injury. It is essential for addressing the underlying deficiency.
Choice C rationale:
Prescribing epoetin intravenously (IV) is used to stimulate the production of red blood cells and treat anemia, but it is not typically associated with an increased risk of injury. However, it should be administered as ordered by the healthcare provider.
Choice D rationale:
Sleeping 8 to 10 hours per night is beneficial for overall health and well-being. It does not increase the client's risk of injury. In fact, adequate sleep can help with tissue repair and overall recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A laissez-faire leadership style is characterized by a lack of involvement or control, and it is not typically associated with perpetrators of child abuse.
Choice B rationale:
Self-blame for financial problems may lead to stress but is not a characteristic finding of perpetrators of child abuse.
Choice C rationale:
High self-esteem is not typically associated with perpetrators of child abuse. In fact, abusers often have low self-esteem and exert power and control over others to compensate for it.
Choice D rationale:
Perpetrators of child abuse often have rigid expectations of behavior from their children and may employ authoritarian parenting styles. This characteristic can contribute to abusive behaviors.
Correct Answer is A
Explanation
Choice A rationale:
It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.
Choice B rationale:
Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.
Choice C rationale:
Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.
Choice D rationale:
Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.
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