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

None

Answer and Explanation

The Correct Answer is A

Pernicious anemia is caused by a deficiency of vitamin B12, which is essential for red blood cell production and neurological function. Clients with this condition often experience glossitis (inflammation of the tongue) and oral mucosal atrophy, making the oral tissues fragile and more prone to injury. Using a firm-bristled toothbrush can cause gum trauma, leading to bleeding, ulcers, and discomfort. A soft-bristled toothbrush is recommended to minimize the risk of injury.

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Correct Answer is A

Explanation

The correct answer is A.

Provide frequent reorientation after ECT. The rationale is that ECT can cause temporary memory loss and confusion, which can be distressing for the client. The nurse should help the client recall their name, location, date, and reason for ECT. The nurse should also reassure the client that their memory will improve over time.

A. Request a PRN restraint prescription for clients who are aggressive. B. Remove the client's restraint every 4 hr. C. Attach the restraint to the bed's side rails. D. Document the client’s condition after every 15 minutes

Correct Answer is D

Explanation

The correct answer is choice D. Document the client’s condition after every 15 minutes.

Choice A rationale:

Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used as a last resort and not on a PRN basis. Restraints should be used only when necessary to ensure the safety of the patient and others, and always with a specific, time-limited order.

Choice B rationale:

Removing the client’s restraint every 4 hours is not frequent enough. Restraints should be removed more frequently to assess the patient’s condition, provide care, and ensure that the restraint is still necessary.

Choice C rationale:

Attaching the restraint to the bed’s side rails is unsafe. Restraints should be attached to a part of the bed frame that moves with the patient to prevent injury.

Choice D rationale:

Documenting the client’s condition every 15 minutes is the correct guideline. Frequent documentation ensures that the patient’s condition is continuously monitored, and any changes can be addressed promptly to ensure safety and well-being.

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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

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Explanation

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