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 D
Explanation
Choice A Reason:
Documenting the infiltration is important for the client's medical record, but it should not be the first action when infiltration is suspected.
Choice B Reason:
Elevating the arm can help reduce swelling, but it should come after stopping the infusion.
Choice C Reason:
Applying a warm compress can help with comfort and may be done after stopping the infusion, but it is not the first action.
Choice D Reason:
Stop the infusion is correct. When a nurse observes signs of infiltration around an IV insertion site, such as edema and coolness of the skin, the first and most important action is to stop the infusion immediately. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. Stopping the infusion prevents further damage to the surrounding tissue and minimizes the risk of complications.
Correct Answer is C
Explanation
When collecting a stool specimen to check for occult blood, it is important to avoid certain foods that can affect the test results, such as red meat. Red meat can cause false-positive results due to the presence of heme, which can mimic the appearance of blood in the stool.
By avoiding red meat for at least three days before the test, the client can help ensure more accurate results. pasteurized dairy products do not have a direct impact on stool occult blood test results. However, it is important to note that certain medications, such as bismuth subsalicylate (found in Pepto-Bismol), can affect the test results.
The presence of urine in the stool sample can potentially dilute or mask the presence of blood, leading to false-negative results. It is important
Occult blood testing is typically done as a one-time test unless otherwise specified by a healthcare provider. Collecting a specimen once each week for four weeks is unnecessary unless specifically instructed by the healthcare provider.
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