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

The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.

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Correct Answer is C

Explanation

The correct answer is C.

Check the child for oral injuries. The rationale is that during a tonic-clonic seizure, the child may bite their tongue, cheek or lips and cause bleeding or damage to their oral tissues. The nurse should inspect the child's mouth for any injuries and provide appropriate care.

A. Complete an incident report. B. Notify the client's provider. C. Document the fall in the client's medical record. D. Measure the client's vital signs.

Correct Answer is D

Explanation

The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.

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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 caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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