The husband of an older adult woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. Which action should the nurse take?
Ask if the client is experiencing any change in bowel habits.
Determine if the client is taking iron and folic acid supplements.
Encourage the husband to bring the client to the clinic for a complete blood count.
Explain that memory loss and confusion are common with vitamin B12 deficiency.
The Correct Answer is D
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Monitor collection container and replace when full: The nurse should monitor the collection container to ensure it doesn't become full, as this could cause backflow into the pleural cavity. Replacing it when full is essential to maintain proper drainage.
B. Encourage frequent use of the incentive spirometer: Using the incentive spirometer helps prevent atelectasis and pneumonia by promoting lung expansion. It is important for postoperative recovery to maintain good respiratory function.
C. Assess area around chest tube for subcutaneous emphysema: Subcutaneous emphysema can occur if air leaks into the tissues around the chest tube. The nurse should check for this condition as it could indicate complications like an air leak or pneumothorax.
D. Keep tubing loosely coiled below the level of the chest: The tubing should be positioned below the chest to facilitate gravity drainage. Keeping it loosely coiled ensures that fluid and air drain efficiently without backflow.
E. Verify air bubbling present in the water seal chamber: Continuous bubbling in the water seal chamber is not expected and may indicate an air leak. Intermittent bubbling may be normal if the lung is still re-expanding, but ongoing bubbling should be reported, not simply verified.
Correct Answer is C
Explanation
A. Suggest to the client that he take a walk: Allowing pacing might escalate the agitation or delusions, especially in a stimulating environment. This does not address the immediate need to reduce stimuli.
B. Use firmness and direct the client to sit for a while: Direct commands may increase the client's agitation or trigger a confrontation if the client feels threatened or challenged while delusional.
C. Move the client to a quiet place on the unit: Reducing environmental stimuli by relocating the client to a low-stimulation setting can help de-escalate the situation and prevent further loss of control.
D. Encourage the client to use the punching bag: Promoting physical aggression even if directed at an object may reinforce violent behavior and is inappropriate during acute delusional episodes.
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