Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Uses a firm-bristled toothbrush
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.
B. Increased intake of green, leafy vegetables
Green, leafy vegetables are rich in folic acid, which supports red blood cell production. However, pernicious anemia is specifically caused by vitamin B12 deficiency, not folate deficiency.
C. Drinks 2,500 mL of fluid per day
Adequate hydration does not contribute to injury risk in pernicious anemia. In fact, maintaining proper fluid intake helps prevent dehydration and supports overall circulation.
D. Wears a face mask around others
Wearing a face mask does not increase the risk of injury. It may actually help protect the client from infections if they have weakened immunity due to anemia.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?
A. "If I were you, I would contact your spiritual director."
B. "You have a right to change your mind."
"You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.
C. "Making this decision is wrong."
D. "I'm sure that everything will be all right, regardless of your decision."
Full Explanation
The correct answer is B. "You have a right to change your mind." This response respects the client's autonomy and informs them that they can reconsider their decision if they wish. The other responses are inappropriate and should be avoided. "If I were you, I would contact your spiritual director." implies that the nurse does not support the client's decision and tries to persuade them to change it. "Making this decision is wrong." is judgmental and disrespectful of the client's beliefs and values. "I'm sure that everything will be allright, regardless of your decision." is false reassurance and minimizes the potential consequences of the client's decision.
A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hr creatinine clearance test. Which of the following statements should the nurse include in the teaching?
A. "You can begin collection of urine after discarding your first morning void."
The client should begin collecting urine after discarding the first morning void, which is not part of the 24-hr period. The client should avoid eating a protein-rich diet during the collection period, as this can affect the creatinine level. The client does not need to cleanse the perineal area with an antiseptic towel each time before voiding, as this is not necessary for a creatinine clearance test. The client does not need to record the blood glucose level each time they void, as this is not related to the creatinine clearance test.
B. "You should eat a protein-rich diet during the collection period."
C. "You can cleanse your perineal area with an antiseptic towel each time before you void."
D. "You should record your blood glucose level each time you void."
Full Explanation
The correct answer is A. The client should begin collecting urine after discarding the first morning void, which is not part of the 24-hr period. The client should avoid eating a protein-rich diet during the collection period, as this can affect the creatinine level. The client does not need to cleanse the perineal area with an antiseptic towel each time before voiding, as this is not necessary for a creatinine clearance test. The client does not need to record the blood glucose level each time they void, as this is not related to the creatinine clearance test.
A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
A. The client fell because the assistive personnel did not place nonskid slippers on the client."
B. The client does not appear to have any injuries resulting from the fall."
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'."
The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
D. "An incident report has been completed and sent to risk management."
Full Explanation
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.