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 B
Explanation
This statement demonstrates an understanding of the concept of spacing out immunizations to reduce the number of shots given during a single visit. By making multiple office visits, the parent can ensure that their child receives the recommended immunizations while minimizing the number of injections at each visit.
Lactose intolerance is not a contraindication to receiving immunizations. Most vaccines do not contain lactose, and even if they do, the amount present is typically minimal and not expected to cause an adverse reaction in individuals with lactose intolerance.
The first flu immunization is typically recommended for children starting at 6 months of age, not at 6 years of age.
The human papillomavirus (HPV) vaccine is typically recommended for preteens and adolescents, usually starting between the ages of 11 and 12. It is not typically administered when a child enters kindergarten.
Correct Answer is D
Explanation
Choice A Reason:
Positioning the knot of the rope at the top of the pulley is incorrect. The knot should be placed at the foot of the bed to ensure proper traction.
Choice B Reason:
Removing the weights for 20 minutes without a healthcare provider's order is not appropriate. If the client experiences severe pain, the nurse should assess the client, evaluate the traction system, and notify the healthcare provider if necessary.
Choice C Reason:
Applying 6.8 kg (15 lb) of weight for use in traction is not the standard practice. The amount of weight used in Buck's traction varies depending on the healthcare provider's orders and the client's specific condition. The nurse should follow the healthcare provider's orders regarding the amount of weight to apply.
Choice D Reason:
Compare bilateral pedal pulses. When caring for a client with Buck's traction, it is essential to regularly assess the circulation to the extremity in traction. Comparing bilateral pedal pulses helps the nurse determine if there are any circulation issues in the affected leg. If the client's circulation is compromised, it can lead to complications such as deep vein thrombosis (DVT) or compartment syndrome.
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