# A nurse is caring for a 32-year-old client with a history of peptic ulcer disease who has been taking omeprazole 40 mg daily for the past 6 months. The client reports recently feeling weak and fatigued. Based on the client's medication history and symptoms, which assessment is most appropriate for the nurse to perform? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=177301 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 32-year-old client with a history of peptic ulcer disease who has been taking omeprazole 40 mg daily for the past 6 months. The client reports recently feeling weak and fatigued. Based on the client's medication history and symptoms, which assessment is most appropriate for the nurse to perform? ## 보기 1. Monitor for signs of gastric bleeding and melena 2. Assess for drug interactions with warfarin therapy 3. Evaluate compliance with dietary restrictions 4. Monitor for signs of vitamin B12 deficiency and anemia **✔ 정답** **정답: 4** ## 해설 Long-term PPI therapy impairs vitamin B12 absorption, leading to deficiency and symptoms like weakness and fatigue. The nurse should assess for signs of megaloblastic anemia and neurological symptoms. Other options are less directly related to the client's presentation. ## 심화 해설 Understanding the Clinical Scenario A 32-year-old client with a history of peptic ulcer disease has been on long-term omeprazole therapy at 40 mg daily for 6 months. The client's new report of weakness and fatigue, in the context of this medication history, should immediately prompt the nurse to consider adverse effects related to chronic acid suppression. Why Long-Term PPI Use Leads to Nutrient Deficiency The primary mechanism involves the profound reduction of gastric acid secretion by proton pump inhibitors (PPIs) like omeprazole. Gastric acid is essential for the release of vitamin B12 from food proteins. Without adequate acid, pepsin cannot cleave B12 from its dietary protein carriers, preventing it from binding to R-proteins and later to intrinsic factor for absorption in the terminal ileum. This process, when disrupted over months, depletes hepatic stores and leads to a functional vitamin B12 deficiency [1,2]. Connecting Pathophysiology to the Client's Symptoms The symptoms reported—weakness and fatigue—are classic, nonspecific manifestations of anemia. In the context of prolonged PPI use, the most likely etiology is a developing megaloblastic anemia secondary to vitamin B12 deficiency. The deficiency impairs DNA synthesis in erythrocyte precursors within the bone marrow, leading to large, immature, and often destroyed red blood cells. This results in decreased oxygen-carrying capacity, which the client perceives as fatigue and weakness. While PPIs can also impair the absorption of iron, magnesium, and calcium, the constellation of a 6-month history and generalized fatigue points most directly toward a B12-related process [1,3]. Analysis of the Answer Choices The nurse must prioritize an assessment that directly correlates with the highest risk associated with the specific medication history. - Option 1: Monitor for signs of gastric bleeding and melena. While a history of peptic ulcer disease carries a baseline risk for bleeding, the client is on a therapeutic dose of a PPI, which is the primary treatment to prevent ulcer recurrence and bleeding. There are no new symptoms (e.g., epigastric pain, black tarry stools) to suggest an active bleed. This assessment does not address the most likely cause of the new-onset fatigue related to the medication itself. - Option 2: Assess for drug interactions with warfarin therapy. The scenario provides no information suggesting the client is on warfarin. This assessment is not indicated based on the available data and represents a distraction from the client's actual reported symptoms and medication history. - Option 3: Evaluate compliance with dietary restrictions. While dietary modifications are a component of peptic ulcer disease management, non-compliance would more likely trigger dyspepsia or pain, not isolated fatigue and weakness. This option ignores the direct physiological consequence of the medication. - Option 4: Monitor for signs of vitamin B12 deficiency and anemia. This is the most appropriate assessment. The client has a clear risk factor (chronic PPI use for ≥6 months) and presents with hallmark symptoms of anemia (weakness, fatigue). A focused assessment would include checking for other signs like pallor, glossitis, and peripheral neuropathy, and anticipating laboratory evaluations such as a complete blood count (CBC) and serum B12 levels [1,2]. A retrospective study found that chronic acid blockade with PPIs is significantly associated with clinically relevant micronutrient deficiencies, including vitamin B12, due to reduced absorption [1]. A separate pharmacovigilance analysis confirmed a significant signal for vitamin B12 deficiency associated with PPI use in a real-world database [2].References (research sources) - [1]Association of Long-Term Proton Pump Inhibitor Use With Nutrient Deficiencies: A Retrospective Cross-Sectional Study.Research articleNafea S, Iguh C, Waseem F, Babar T, Masood MH, Ali MA, Bashir Ahmed F, Qasem H, George Cherian N, Ibrahem Atoom G, Ibrahim Atoum B. (2026) · DOI: 10.7759/cureus.106137 - [2]Vitamin B12 Deficiency Associated with Metformin and Proton Pump Inhibitors and Their Combinations: Results from a Disproportionality and Interaction Analysis.Research articleSridharan K. (2025) · DOI: 10.3390/diseases13100334 ## 임상 시나리오 PPI-Induced B12 Deficiency AssessmentLinking Long-Term Acid Suppression to Anemia Long-term use of proton pump inhibitors like omeprazole can lead to vitamin B12 deficiency by reducing gastric acid needed to release B12 from food proteins. This malabsorption can deplete hepatic stores over 6 months or more. The client's new onset of weakness and fatigue are classic symptoms of megaloblastic anemia secondary to B12 deficiency. The nurse's most appropriate action is to assess for further signs of this deficiency, such as pallor, glossitis, or neurological changes like paresthesia. CautionDo not confuse these symptoms with acute GI bleeding. While PPIs are used for PUD, weakness and fatigue without overt bleeding signs in a long-term PPI user should prioritize a nutritional deficiency workup. ## 핵심 개념 - **Proton Pump Inhibitors (PPIs)** — A class of medications that cause a profound and prolonged reduction of stomach acid production by blocking the hydrogen/potassium adenosine triphosphatase enzyme system of the gastric parietal cells. - **Vitamin B12 Deficiency Anemia** — A type of megaloblastic anemia caused by insufficient vitamin B12, which is essential for DNA synthesis in red blood cell production, leading to large, abnormal, immature red blood cells and decreased oxygen-carrying capacity. - **Omeprazole** — A proton pump inhibitor used to treat conditions like peptic ulcer disease and GERD by reducing gastric acid secretion; long-term use is associated with impaired absorption of vitamin B12 and other nutrients. - **Megaloblastic Anemia** — A blood disorder characterized by the presence of unusually large, structurally abnormal, immature red blood cells (megaloblasts) in the bone marrow, most often caused by deficiencies of vitamin B12 or folate. - **Intrinsic Factor** — A glycoprotein secreted by the gastric parietal cells that binds to vitamin B12 in the small intestine, facilitating its absorption in the terminal ileum; its function is dependent on an acidic gastric environment. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old male client with epigastric pain. 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