A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

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.

The correct answer is choice B and C.

Choice A rationale:

Cervical insufficiency is a condition where the cervix begins to shorten and open too early during pregnancy, leading to premature birth or loss of an otherwise healthy pregnancy. However, the client’s symptoms do not indicate cervical insufficiency. There are no reports of lower abdominal pressure, mild pelvic cramps, or a change in vaginal discharge, which are common symptoms of cervical insufficiency.

Choice B rationale:

The client’s severe headache unrelieved by acetaminophen, +3 pitting edema in bilateral lower extremities, and hyperactive reflexes (patellar reflex 4+) are indicative of severe preeclampsia. One of the complications of severe preeclampsia is seizures, also known as eclampsia. Therefore, the client is at risk for developing seizures.

Choice C rationale:

Placental abruption is a serious pregnancy complication in which the placenta detaches from the uterus prematurely. The client’s report of decreased fetal movement could be a sign of placental abruption. In addition, severe preeclampsia can increase the risk of placental abruption. Therefore, the client is at risk for developing placental abruption.

Choice D rationale:

Heart failure occurs when the heart can’t pump enough blood to meet the body’s needs. While preeclampsia can eventually affect many organ systems including the cardiovascular system, there are no immediate signs of heart failure in the client’s symptoms.

Choice E rationale:

Hypoglycemia refers to low blood sugar levels. The client’s symptoms do not suggest hypoglycemia. Symptoms of hypoglycemia typically include confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart or irregular heartbeat, sweating, trembling or tremors, and weakness. In conclusion, based on the client’s symptoms and clinical presentation, she is at greatest risk for developing seizures (Choice B) and placental abruption (Choice C) due to severe preeclampsia.