Blood Disorders

The primary purpose of the Schilling test is to measure the client's ability to: 1. Store vitamin B12 2. Digest vitamin B12 3. Absorb vitamin B12 4. Produce vitamin B12

3. Pernicious anemia is caused by the body's inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling's test helps diagnose pernicious anemia by determining the client's ability to absorb vitamin B12.

Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply. 1. "He drinks over 3 cups of milk per day." 2. "I can't keep enough apple juice in the house; he must drink over 10 ounces per day." 3. "He refuses to eat more than 2 different kinds of vegetables." 4. "He doesn't like meat, but he will eat small amounts of it." 5. "He sleeps 12 hours every night and take a 2-hour nap."

1, 2. Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients.

Which of the following blood components is decreased in anemia? 1. Erythrocytes 2. Granulocytes 3. Leukocytes 4. Platelets

1. Anemia is defined as a decreased number of erythrocytes (red blood cells). Leukopenia is a decreased number of leukocytes (white blood cells). Thrombocytopenia is a decreased number of platelets. Lastly, granulocytopenia is a decreased number of granulocytes (a type of white blood cells).

When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions? 1. Bleeding tendencies 2. Intake and output 3. Peripheral sensation 4. Bowel function

1. Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.

Because of the risks associated with administration of factor VIII concentrate, the nurse would teach the client's family to recognize and report which of the following? 1. Yellowing of the skin 2. Constipation 3. Abdominal distention 4. Puffiness around the eyes

1. Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes.

Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis? 1. Child's reluctance to move a body part 2. Cool, pale, clammy extremity 3. Echymosis formation around a joint 4. Instability of a long bone in passive movement

1. Bleeding into the joints in the child with hemophilia leads to pain and tenderness, resulting in restricted movement. Therefore, an early sign of hemarthrosis would be the child's reluctance to move a body part. If the bleeding into the joint continues, the area becomes hot, swollen, and immobile—not cool, pale, and clammy. Ecchymosis formation around a joint would be difficult to assess. Instability of a long bone on passive movement is not associated with joint hemarthrosis.

A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? 1. Hematocrit 2. Partial thromboplastin time 3. Hemoglobin concentration 4. Prothrombin time

1. Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug.

A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance? 1. "What activities were you able to do 6 months ago compared with the present?" 2. "How long have you had this problem?" 3. "Have you been able to keep up with all your usual activities?" 4. "Are you more tired now than you used to be?"

1. It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client's activity tolerance. Also, the client may not even identify that a "problem" exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.

Which of the following symptoms is expected with hemoglobin of 10 g/dl? 1. None 2. Pallor 3. Palpitations 4. Shortness of breath

1. Mild anemia usually has no clinical signs. Palpitations, SOB, and pallor are all associated with severe anemia.

The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? 1. Eggs 2.Lettuce 3. Citrus fruits 4. Cheese

1. One of the microcytic, hypochromic anemias is iron-deficiency amenia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium.

The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client's teaching plan? Select all that apply. 1. Hearing loss 2. Visual disturbance 3. Headache 4. Orthopnea 5. Gout 6. Weight loss

2, 3, 4, 5. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera.

A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs and personal preferences? 1. Egg yolks 2. Brown rice 3. Vegetables 4. Tea

2. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption.

A mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following? 1. Little is known about iron-deficiency anemia and its relationship to infection in children. 2. Children with iron deficiency anemia are more susceptible to infection than are other children. 3. Children with iron-deficiency anemia are less susceptible to infection than are other children. 4. Children with iron-deficient anemia are equally as susceptible to infection as are other children.

2. Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.

The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? 1. Eat animal protein and dark leafy vegetables each day 2. Avoid exposure to others with acute infection 3. Practice yoga and meditation to decrease stress and anxiety 4. Get 8 hours of sleep at night and take naps during the day

2. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.

Which of the following diagnostic findings are most likely for a client with aplastic anemia? 1. Decreased production of T-helper cells 2. Decreased levels of white blood cells, red blood cells, and platelets 3. Increased levels of WBCs, RBCs, and platelets 4. Reed-Sternberg cells and lymph node enlargement

2. In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia). T-helper cell production doesn't decrease in aplastic anemia. Reed-Sternberg cells and lymph node enlargement occur with Hodgkin's disease.

A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse's first response? 1. Assess for potential abuse 2. Check for diminished sensations 3. Document the findings 4. Clean and dress the area

2. Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the client's sensations first. The decision of how to treat the burn should be determined by the physician.

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response? 1. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." 2. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." 3. "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction." 4. "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."

2. Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition.

Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia? 1. Rice cereal, whole milk, and yellow vegetables 2. Potato, peas, and chicken 3. Macaroni, cheese, and ham 4. Pudding, green vegetables, and rice

2. Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron.

The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings? 1. Schilling's test, elevated 2. Intrinsic factor, absent. 3. Sedimentation rate, 16 mm/hour 4. RBCs 5.0 million

2. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia.

Which of the following nursing assessments is a late symptom of polycythemia vera? 1. Headache 2. Dizziness 3. Pruritus 4. Shortness of breath

3. Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange.

The nurse is assessing a client's activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response? 1. Pulse rate increased by 20 bpm immediately after the activity 2. Respiratory rate decreased by 5 breaths/minute 3. Diastolic blood pressure increased by 7 mm Hg 4. Pulse rate within 6 bpm of resting phase after 3 minutes of rest.

2. The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.

The nurse implements which of the following for the client who is starting a Schilling test? 1. Administering methylcellulose (Citrucel) 2. Starting a 24- to 48 hour urine specimen collection 3. Maintaining NPO status 4. Starting a 72 hour stool specimen collection

2. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of nonradioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered.

A child suspected of having sickle cell disease is seen in a clinic, and laboratory studies are performed. A nurse checks the lab results, knowing that which of the following would be increased in this disease? 1. Platelet count 2. Hematocrit level 3. Reticulocyte count 4. Hemoglobin level

3. A diagnosis is established based on a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, and increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

A client with anemia may be tired due to a tissue deficiency of which of the following substances? 1. Carbon dioxide 2. Factor VIII 3. Oxygen 4. T-cell antibodies

3. Anemia stems from a decreased number of red blood cells and the resulting deficiency in oxygen and body tissues. Clotting factors, such as factor VIII, relate to the body's ability to form blood clots and aren't related to anemia, not is carbon dioxide of T antibodies.

The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following? 1. Autoimmune reaction complicated by hypoxia 2. Lack of oxygen in the red blood cells 3. Obstruction to circulation 4. Elevated serum bilirubin concentration.

3. Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of RBCs. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.

A vegetarian client was referred to a dietician for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: 1. Adds dried fruit to cereal and baked goods 2. Cooks tomato-based foods in iron pots 3. Drinks coffee or tea with meals 4. Adds vitamin C to all meals

3. Coffee and tea increase gastrointestinal mobility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

Which of the following would the nurse identify as the priority nursing diagnosis during a toddler's vasoocclusive sickle cell crisis? 1. Ineffective coping related to the presence of a life-threatening disease 2. Decreased cardiac output related to abnormal hemoglobin formation 3. Pain related to tissue anoxia 4. Excess fluid volume related to infection

3. For the child in a sickle cell crisis, pain is the priority nursing diagnosis because the sickled cells clump and obstruct the blood vessels, leading to occlusive and subsequent tissue ischemia. Although ineffective coping may be important, it is not the priority. Decreased cardiac output is not a problem with this type of vasoocclusive crisis. Typically, a sickle cell crisis can be precipitated by a fluid volume deficit or dehydration.

The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? 1. Whole grains 2. Green leafy vegetables 3. Meats and dairy products 4. Broccoli and Brussels sprouts

3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C).

Which of the following disorders results from a deficiency of factor VIII? 1. Sickle cell disease 2. Christmas disease 3. Hemophilia A 4. Hemophilia B

3. Hemophilia A results from a deficiency of factor VIII. Sickle cell disease is caused by a defective hemoglobin molecule. Christmas disease, also called hemophilia B, results in a factor IX deficiency.

A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? 1. Infection 2. Trauma 3. Fluid overload 4. Stress

3. Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 ½ to 2 times the daily requirement to prevent dehydration.

When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate? 1. Check the dressing and drains for frank bleeding 2. Call the physician 3. Continue to monitor vital signs 4. Start oxygen at 2L/min per NC

3. The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client's hematocrit reflects a falsely high value related to the body's compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the client's hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit.

Which of the following cells is the precursor to the red blood cell (RBC)? 1. B cell 2. Macrophage 3. Stem cell 4. T cell

3. The precursor to the RBC is the stem cell. B cells, macrophages, and T cells and lymphocytes, not RBC precursors.

A pediatric nurse health educator provides a teaching session to the nursing staff regarding hemophilia. Which of the following information regarding this disorder would the nurse plan to include in the discussion? 1. Hemophilia is a Y linked hereditary disorder 2. Males inherit hemophilia from their fathers 3. Females inherit hemophilia from their mothers 4. Hemophilia A results from a deficiency of factor VIII

4. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X-chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX.

The physician has ordered several laboratory tests to help diagnose an infant's bleeding disorder. Which of the following tests, if abnormal, would the nurse interpret as most likely to indicate hemophilia? 1. Bleeding time 2. Tourniquet test 3. Clot retraction test 4. Partial thromboplastin time (PTT)

4. PTT measures the activity of thromboplastin, which is dependent on intrinsic clotting factors. In hemophilia, the intrinsic clotting factor VIII (antihemiphilic factor) is deficient, resulting in a prolonged PTT. Bleeding time reflects platelet function; the tourniquet test measures vasoconstriction and platelet function; and the clot retraction test measures capillary fragility. All of these are unaffected in people with hemophilia.

A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan? 1. "Take the medication with an antacid." 2. "Take the medication with a glass of milk." 3. "Take the medication with cereal." 4. "Take the medication on an empty stomach."

4. Preferably, ferrous gluconate should be taken on an empty stomach. Ferrous gluconae should not be taken with antacids, milk, or whole-grain cereals because these foods reduce iron absorption.

The mothers asks the nurse why her child's hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate? 1. "The placenta bars passage of the hemoglobin S from the mother to the fetus." 2. "The red bone marrow does not begin to produce hemoglobin S until several months after birth." 3. "Antibodies transmitted from you to the fetus provide the newborn with temporary immunity." 4. "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."

4. Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborns hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.

The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? 1. Total bilirubin, 0.3 mg/dL 2. Serum creatinine, 0.5 mg/dL 3. Hemoglobin, 16 g/dL 4. Folate, 1.5 ng/mL

4. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? 1. An elevated hemoglobin level 2. A decreased reticulocyte count 3. An elevated RBC count 4. Red blood cells that are microcytic and hypochromic

4. The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? 1. "I have been drinking plenty of fluids." 2. "I have been gargling with warm salt water for my sore tongue." 3. "I have 3 to 4 loose stools per day." 4. "I take a vitamin B12 tablet every day."

4. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needw to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohn's disease and small bowel resection may cause several loose stools a day.

A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse's best response to relieve these fears? 1. "Vitamin B12 will cause ringing in the eats before a toxic level is reached." 2. "Vitamin B12 may cause a very mild skin rash initially." 3. "Vitamin B12 may cause mild nausea but nothing toxic." 4. "Vitamin B12 is generally free of toxicity because it is water soluble."

4. Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body's needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration.