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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"This medication prevents your baby from developing bleeding problems." This is the correct statement. Phytonadione is given to newborns to prevent neonatal vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including intracranial hemorrhage.
Choice B Reason:
"This medication enhances regulation of your baby's temperature." Phytonadione does not have any direct impact on the regulation of a baby's temperature. Its primary purpose is to prevent bleeding issues.
Choice C Reason:
"This medication enhances your baby's immune response. Phytonadione does not enhance a baby's immune response. It primarily addresses vitamin K deficiency and associated bleeding risks.
Choice D Reason:
"This medication prevents your baby from developing jaundice." Phytonadione is not used to prevent jaundice. Jaundice is typically related to bilirubin levels and is managed separately from vitamin K supplementation.
Correct Answer is B
Explanation
Choice A Reason:
Decreased BUN (blood urea nitrogen) level is incorrect. While furosemide can lead to decreased BUN levels, it is not the primary indicator of its effectiveness. BUN levels can be influenced by various factors, including hydration status and kidney function.
Choice B Reason:
Increased urinary output is correct. Furosemide is a diuretic medication often prescribed to clients with heart failure to help manage fluid retention. One of the primary therapeutic effects of furosemide is increased urinary output, which indicates that the medication is effectively removing excess fluid from the body.
Choice C Reason:
Decreased hemoglobin level is incorrect. Furosemide is not directly associated with changes in hemoglobin levels. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are typically not affected by diuretic therapy.
Choice D Reason:
Increased weight of 0.91 kg (2 lb.) is incorrect. An increase in weight is not indicative of the medication's effectiveness. In fact, weight gain could be a sign of fluid retention and heart failure exacerbation, which would suggest that the medication may not be working optimally.
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