A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Assess the client for nerve pain or paralysis.

Ensure the client has minimal clutter in the room.

Evaluate the client's neurological status after exercising.

Monitor the client's blood cell laboratory values.

Answer and Explanation

The Correct Answer is B

To prevent injury in a female client with immune thrombocytopenic purpura (ITP) who is transferred to a long-term care facility for physical rehabilitation, the most important action for the practical nurse to implement is to ensure the client has minimal clutter in the room.

ITP is a condition characterized by a low platelet count, which can result in an increased risk of bleeding and bruising. Clutter in the room can pose a hazard and increase the risk of injury. The client may accidentally bump into objects or trip over items, potentially leading to falls or injuries.

Incorrect:

A- Assessing the client for nerve pain or paralysis is important but may not be directly related to preventing injury in this context. It is essential to address these concerns but not the most important action in preventing injury.

C- Evaluating the client's neurological status after exercising is important for overall assessment and monitoring but does not specifically address the prevention of injury.

D- Monitoring the client's blood cell laboratory values is essential for managing the client's condition but does not directly address preventing injury. It focuses more on the medical management of the client's ITP.

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Correct Answer is A

Explanation

A. "Are you planning to obey the voices?" – This question is crucial as it assesses the immediate risk of harm to the client or others. Determining if the client intends to follow commands from hallucinations provides insight into potential danger, ensuring safety is prioritized.

B. "Have you taken any hallucinogens?" – While drug use can contribute to hallucinations, asking about substance use is less urgent than assessing potential harm from the voices. Immediate safety takes precedence over exploring potential causes at this stage.

C. "When did these voices begin?" – Knowing when the symptoms started is relevant for understanding the history of the hallucinations but is secondary to determining if the client intends to act on any commands from the voices, as safety is the first priority.

D. "Do you believe the voices are real?" – This question helps assess the client’s insight into the hallucinations but is not as critical as assessing the immediate risk of harm by determining if the client plans to follow any commands from the voices.

A. A picnic in the park. B. An outdoor concert. C. An outdoor game of balloon volleyball. D. A tea party in the courtyard.

Correct Answer is C

Explanation

The activity that the PN should suggest to meet the physical and social needs of wheelchair-bound older residents who are mentally alert is an outdoor game of balloon
volleyball. It promotes physical activity, coordination, and social interaction among the residents. It allows them to engage with each other, participate in a fun and inclusive game, and enjoy the outdoor environment. Balloon volleyball can be adapted to accommodate individuals with varying abilities and provide an enjoyable and stimulating experience for wheelchair-bound residents who are mentally alert.
A. A picnic in the park: While a picnic in the park can be enjoyable, it may pose challenges for wheelchair-bound individuals in terms of accessibility and maneuverability. It might limit their participation and engagement in the activity.
B. An outdoor concert: While an outdoor concert can be entertaining, it may not actively engage wheelchair-bound residents. They may be limited in their ability to fully participate and interact with others during the concert.
D. A tea party in the courtyard: While a tea party can be a pleasant social activity, it may not provide the desired physical engagement for wheelchair-bound residents. They may require activities that involve more movement and physical participation.

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A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

Correct Answer is A

Explanation

The practical nurse (PN) is assisting the recreational director of a long-term care facility in planning outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity should the PN suggest that meets the physical and social needs of these residents?

Correct Answer is C

Explanation

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