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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Effleurage is a massage technique commonly used during labor to provide comfort and relaxation. It involves using gentle, rhythmic stroking movements on the abdomen during contractions. This technique can help relieve tension, promote relaxation, and provide distraction from the intensity of the contractions.

Deep breathing techniques are often used during labor to promote relaxation and manage pain. However, this instruction does not specifically relate to effleurage.

Focusing on an object in the room, such as a focal point, can be a helpful technique during labor to redirect attention and manage pain. However, this instruction does not specifically relate to effleurage.

Applying pressure to the sacral area can help alleviate back pain during labor. However, this instruction describes the use of a tennis ball and is not specifically related to effleurage.

A. Potassium 3.5 mEq/L B. Sodium 130 mEq/L C. Hgb 10 g/dL D. BMI 14.5

Correct Answer is A

Explanation

The normal range for potassium levels is generally between 3.5 to 5.0 mEq/L. A potassium level of 3.5 mEq/L falls within the lower end of the normal range, suggesting that the client's potassium levels are relatively stable. This finding alone does not indicate the overall effectiveness of the behavioral plan.

The normal range for sodium levels is typically between 135 to 145 mEq/L. A sodium level of 130 mEq/L falls below the normal range and indicates hyponatremia (low sodium levels). Hyponatremia can be a cause for concern, and it suggests that the behavioral management plan may need further attention or adjustments.

The normal range for hemoglobin (Hgb) levels varies depending on factors such as age and gender. However, in general, a Hgb level of 10 g/dL falls below the normal range and indicates anemia. Anemia is a common complication in individuals with anorexia nervosa and can result from inadequate nutrient intake. This finding suggests that the behavioral plan may need further evaluation and adjustment to address the client's nutritional needs.

Body Mass Index (BMI) is a measure that relates weight and height. A BMI of 14.5 indicates severe underweight and is well below the normal range. This finding suggests that the client's nutritional status is still significantly compromised, and the behavioral management plan may require further attention to support weight restoration and overall recovery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

Correct Answer is C

Explanation

A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

Correct Answer is A

Explanation

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