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
Choice A Reason:
Shrimp salad: Shrimp is a type of shellfish, and shellfish are not allowed in a kosher diet.
Choice B Reason:
Roasted salmon. When caring for a client who follows a kosher diet, it's important to provide food that adheres to kosher dietary laws. Kosher dietary laws prohibit the consumption of certain types of seafood (like shrimp and clams) and pork products (like pulled-pork). Therefore, shrimp salad, clam chowder, and pulled-pork sandwich are not suitable for a kosher diet. Roasted salmon, on the other hand, is an acceptable choice for a kosher diet as long as it has been prepared following kosher guidelines. Fish with fins and scales, such as salmon, are generally considered kosher.
Choice C Reason:
Pulled-pork sandwich: Pork is strictly prohibited in a kosher diet, and any pork-based products, including pulled-pork, are not allowed.
Choice D Reason:
Clam chowder: Clams are considered shellfish, and like other shellfish, they are not permitted in a kosher diet.
Correct Answer is D
Explanation
Choice A Reason:
Limiting fluid intake to 750 mL per day is not recommended, as adequate hydration is essential for overall health. The client should maintain good hydration unless specifically advised otherwise by their healthcare provider.
Choice B Reason:
Cleansing the neck by rubbing with a washcloth may be too harsh for the irradiated skin. The skin in the radiation field can become sensitive and may require gentle cleansing with mild soap and patting dry, rather than rubbing.
Choice C Reason:
Eating three large meals each day may not be suitable for all clients undergoing radiation therapy, especially if they are experiencing side effects such as difficulty swallowing or changes in taste. Dietary recommendations should be individualized based on the client's specific needs and symptoms. Smaller, more frequent meals may be more manageable for some clients.
Choice D Reason:
Avoiding exposing the neck to the cold is correct. When providing instructions to a client undergoing radiation therapy to the neck, it's important to emphasize the need to protect the treated area from extreme temperature changes. Exposure to cold temperatures can cause vasoconstriction and potentially lead to tissue damage in the irradiated area. Therefore, advising the client to avoid exposing the neck to cold is a vital precaution.
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