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.

Prescribed vitamin B12 IM.

Prescribed epoetin IV.

Sleeps 8 to 10 hr per night.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Using a firm-bristled toothbrush can increase the risk of gum injury or bleeding, especially in individuals with pernicious anemia who may have fragile gums due to vitamin B12 deficiency. This choice is correct because it identifies a risk factor for injury.

Choice B rationale:

Prescribing vitamin B12 intramuscularly (IM) is the appropriate treatment for pernicious anemia and does not increase the client's risk of injury. It is essential for addressing the underlying deficiency.

Choice C rationale:

Prescribing epoetin intravenously (IV) is used to stimulate the production of red blood cells and treat anemia, but it is not typically associated with an increased risk of injury. However, it should be administered as ordered by the healthcare provider.

Choice D rationale:

Sleeping 8 to 10 hours per night is beneficial for overall health and well-being. It does not increase the client's risk of injury. In fact, adequate sleep can help with tissue repair and overall recovery.

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Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Bradycardia is not typically associated with a perforated appendix. Instead, tachycardia (increased heart rate) may occur due to pain and infection-related systemic responses. Bradycardia could indicate other unrelated medical issues and should still be monitored.

Choice B rationale: Elevated temperature is a key sign of infection and inflammation, which are common with a perforated appendix. The release of bacteria into the abdominal cavity can cause peritonitis, leading to fever as part of the body's immune response.

Choice C rationale: Lethargy can be a nonspecific symptom and may occur in various conditions. While it can be associated with severe infection, it is not a definitive indicator of a perforated appendix. Monitoring for more specific signs, like fever and pain, is crucial.

Choice D rationale: Decreased abdominal girth is unlikely and not indicative of a perforated appendix. Instead, an increase in abdominal girth due to fluid accumulation (ascites) or air (from perforation) would be more concerning and should be reported promptly.

A. Inquire about the client's bedtime routine. B. Recommend that the client go for a walk every morning. C. Instruct the client to turn off the television before bedtime. D. Encourage the client to listen to soft music at the onset of stress.

Correct Answer is A

Explanation

Choice A rationale:

Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.

Choice B rationale:

Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.

Choice C rationale:

Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.

Choice D rationale:

Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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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?