A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?

Loss of hearing

Muscle wasting

Paresthesia

Changes in vision

Answer and Explanation

The Correct Answer is C

C. Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
A. Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.

D. While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.

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Correct Answer is D

Explanation

D. Capillary refill time greater than 2 seconds suggests impaired peripheral circulation, which could indicate vascular compromise or inadequate perfusion to the extremity. In a client with an external fixator, compromised circulation could lead to serious complications such as compartment syndrome or tissue necrosis.
A. This finding may be within the expected range for drainage following surgery, particularly if the client has undergone orthopedic surgery involving the placement of an external fixator. However, the nurse should continue to monitor the drainage and assess for any signs of increased bleeding or hematoma formation.
B. While a low-grade fever alone may not require immediate intervention, the nurse should assess the client further for other signs and symptoms of infection, such as increased pain, redness, warmth, or drainage at the surgical site.
C. While the client's pain level of 7 may require intervention to manage discomfort, it does not necessarily indicate an immediate threat to the client's safety or well-being.

A. A B. B C. C D. None

Correct Answer is B

Explanation

The transverse colon is located across the right upper quadrant, epigastrium and the left upper quadrant.

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A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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