The husband of an older adult woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. Which action should the nurse take?
Ask if the client is experiencing any change in bowel habits.
Determine if the client is taking iron and folic acid supplements.
Encourage the husband to bring the client to the clinic for a complete blood count.
Explain that memory loss and confusion are common with vitamin B12 deficiency.
The Correct Answer is D
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.
B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.
C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.
D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.
Correct Answer is B
Explanation
A. Encourage the parent to apply lotion with each diaper change: Lotions are not usually recommended for diaper rash as they can trap moisture against the skin, worsening irritation. Barrier creams (like zinc oxide) are preferred.
B. Instruct the parent to change the child's diaper more often: Frequent diaper changes help keep the area dry and clean, reducing skin irritation and promoting healing, especially when there's no sign of infection or allergy.
C. Ask the parent to decrease the infant's intake of fruits for 24 hours: There’s no indication that diet is contributing to the rash, especially since there are no watery stools or other signs of gastrointestinal upset.
D. Tell the parent to cleanse with soap and water at each diaper change: Using soap can dry or irritate already sensitive skin. Plain water or gentle wipes without alcohol/fragrance are preferred for cleaning the area.
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