Nokea
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
- A. Loss of hearing
- B. Paresthesia
- C. Muscle wasting
- D. Changes in vision
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia is caused by a lack of vitamin B12, leading to nerve damage. Paresthesia, or tingling and numbness in the extremities, is a common symptom. This poses a risk to the client's safety as it may result in decreased sensation and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are not directly associated with pernicious anemia and do not pose an immediate safety risk in this context.
You may also like to solve these questions
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Phlebitis
Correct Answer: B
Rationale: The correct answer is B: Infection. When IV tubing is kinked, it can lead to a backflow of urine from the catheter into the tubing, increasing the risk of contamination and subsequent urinary tract infection. Additionally, when the urinary catheter bag is lying next to the client in bed, there is a higher chance of accidental contamination. Infections can lead to serious complications and require prompt intervention. Neurogenic bladder (A) is related to nerve damage affecting bladder control, not directly related to the current situation. Skin breakdown (C) may occur due to prolonged contact with urine but is not the immediate concern here. Phlebitis (D) is inflammation of a vein, not directly linked to the urinary catheter issue.
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
- A. Limit fluids to 1.5 L per day
- B. Avoid extremely hot or cold temperatures
- C. Avoid getting a flu vaccination
- D. Limit alcohol intake to one drink per day
Correct Answer: B
Rationale: The correct answer is B: Avoid extremely hot or cold temperatures. This instruction is important for a client recovering from a sickle cell crisis because extreme temperatures can trigger vaso-occlusive episodes. Sickle cell disease causes red blood cells to become rigid and sticky, leading to blockages in blood vessels, which can be exacerbated by temperature extremes. Limiting exposure to extreme temperatures can help reduce the risk of complications.
A: Limiting fluids is not the priority in this situation. Adequate hydration is important to prevent dehydration and maintain blood flow.
C: Getting a flu vaccination is actually recommended for clients with sickle cell disease, as they are at higher risk of complications from the flu.
D: Limiting alcohol intake is generally advisable, but it is not the most crucial instruction for someone recovering from a sickle cell crisis.
A nurse is planning care for a client who has *Clostridium difficile* gastroenteritis. Which of the following is an appropriate nursing action?
- A. Place the client in a protective environment
- B. Clean surfaces with chlorhexidine
- C. Obtain a stool specimen with gloves
- D. Wash hands with alcohol-based hand rub
Correct Answer: C
Rationale: The correct answer is C: Obtain a stool specimen with gloves.
Rationale:
1. Clostridium difficile is transmitted through contact with feces, so obtaining a stool specimen with gloves is essential to prevent the spread of infection.
2. Using gloves during specimen collection reduces the risk of contaminating hands and surfaces.
3. It is important to identify the specific pathogen causing the gastroenteritis to determine the appropriate treatment.
Summary of incorrect choices:
A: Placing the client in a protective environment is not necessary for Clostridium difficile gastroenteritis.
B: Cleaning surfaces with chlorhexidine is important for infection control but not the most appropriate action in this scenario.
D: Washing hands with alcohol-based hand rub is important for general infection control but not specific to obtaining a stool specimen.
Overall, choice C is the most relevant and appropriate nursing action in this situation.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (A) and distended abdomen (B) are more indicative of right-sided heart failure. Confusion (C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom dark at night.
- B. Cover electrical outlets in the client's home with tape.
- C. Hang a monthly calendar in the client's bedroom.
- D. Place a large face clock in the client's bedroom.
Correct Answer: D
Rationale: The correct answer is D: Place a large face clock in the client's bedroom. This is important for clients with Alzheimer's disease as it helps them maintain a sense of time and routine. People with Alzheimer's often struggle with time perception, so having a clock with large, easy-to-read numbers can assist them in understanding the time of day. This can help reduce confusion and anxiety.
A: Keeping the client's bedroom dark at night may increase confusion and disorientation for someone with Alzheimer's.
B: Covering electrical outlets with tape is not relevant to caring for a client with Alzheimer's at home.
C: Hanging a monthly calendar in the client's bedroom may not be as effective as a large face clock in helping the client understand time.