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A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?

[Select All that Apply)

Mood changes

Mobility challenges

Shortness of breath

Sleep disturbance

Answer and Explanation

Correct Answer : A,B,C,D

A. Mood changes: Deficiency can cause neurological changes, including depression and mood swings.

B. Mobility challenges: Neuropathy and muscle weakness can lead to mobility issues.

C. Shortness of breath: Anemia from B12 deficiency reduces oxygen delivery, causing dyspnea.

D. Visual deficit: Neurological impairment from B12 deficiency can affect the optic nerve, leading to visual disturbances.

E. Sleep disturbance: This is not a typical manifestation of B12 deficiency and is more likely related to other factors.

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Correct Answer is B

Explanation

A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not an escharotomy.

B. "Large incisions will be made in the eschar to improve circulation." An escharotomy involves making large incisions through the eschar (the tough, leathery scab or crust that forms over a severely burned area) to relieve pressure and improve blood flow to the affected area. This procedure is often necessary to prevent complications such as compartment syndrome and to enhance circulation in burn patients.

C. "The procedure involves placing the client into a shower and removing the dead tissue.": This describes debridement, not an escharotomy.

D. "Dead tissue will be non-surgically removed.": Non-surgical removal of dead tissue is debridement, not an escharotomy, which is a surgical procedure.

A. Massage over erythematous bony prominences. B. Implement a turning schedule every 4 hr. C. Keep the client's skin dry with powder. D. Minimize skin exposure to moisture. E. Use pillows to keep heels off the bed surface

Correct Answer is ["B","E"]

Explanation

A. Massage over erythematous bony prominences: Incorrect. Massaging over areas of erythema (redness) can cause further damage to the underlying tissues and should be avoided. It may exacerbate tissue injury and increase the risk of skin breakdown.

B. Use pillows to keep heels off the bed surface: Correct. Elevating the heels with pillows helps to reduce pressure and prevent pressure ulcers by keeping them off hard surfaces. This is a recommended practice to reduce the risk of heel pressure ulcers.

C. Implement turning schedule every 4 hr: Incorrect. A turning schedule of every 2 hours is generally recommended to prevent pressure ulcers. Four hours is too long and increases the risk of skin breakdown in immobile patients.

D. Keep the client's skin dry with powder: Incorrect. Powders can dry out the skin and increase friction, potentially leading to skin breakdown. It's more important to maintain moisture balance and avoid the use of powders on skin at risk.

E. Minimize skin exposure to moisture: Correct. Moisture can contribute to skin breakdown, especially in incontinent patients. It is crucial to keep the skin clean and dry to prevent moisture-associated skin damage.

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A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Correct Answer is B

Explanation

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

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A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?

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