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?

Choice A Reason:

Chloasma is incorrect. Chloasma, also known as the "mask of pregnancy," refers to the brownish or tan patches of pigmentation that can appear on the face during pregnancy. It is not related to the purplish discoloration of the cervix, vagina, and vulva described in the scenario.

Choice B Reason:

Hegar's sign is incorrect. Hegar's sign is a softening and compressibility of the lower uterine segment (the area between the cervix and the body of the uterus) that can be felt during a pelvic examination. It is not related to discoloration of the genital area.

Choice C Reason:

Ballottement is incorrect. Ballottement is a technique used during a pelvic examination to assess the fetus's position and is characterized by the examiner feeling a rebound movement of the fetus when it is pushed and then released. It does not involve discoloration of the genital area.

Choice D Reason:

Chadwick's sign is a bluish-purple or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. This discoloration is due to increased blood flow to the pelvic area and is considered a normal physiological change during pregnancy. It is one of the early signs of pregnancy and can be observed as early as the sixth week of gestation. It is named after the American obstetrician James Read Chadwick, who first described it.

Choice A Reason:

Document objective findings about the situation is incorrect. While documentation is important, it should not be the first action when the charge nurse suspects a colleague is under the influence of alcohol. Patient safety takes precedence, and immediate action to remove the nurse from patient care is necessary to prevent potential harm.

Choice B Reason;

Assigning clients to the remaining staff is incorrect. Assigning clients to other staff members is an appropriate step but should come after the nurse under suspicion has been removed from patient care to ensure their safety. Patient safety is the primary concern.

Choice C Reason:

Calling the supervisor to ask for another nurse is incorrect. Contacting the supervisor is a reasonable action, but it should be done after the immediate safety concern has been addressed by removing the nurse from patient care. This allows the supervisor to be informed of the situation and take appropriate action.

Choice D Reason:

Removing the nurse from the client care area is correct.When a charge nurse detects the smell of alcohol on a nurse's breath, the first and most immediate action should be to remove the nurse from the client care area to ensure patient safety. Alcohol impairment can severely compromise a nurse's ability to provide safe and effective care. Once the nurse is removed from patient care, further actions, such as documenting objective findings and contacting the supervisor, can be taken to address the situation and ensure appropriate follow-up, including any necessary interventions or investigations. Patient safety should always be the top priority in such situations.