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.
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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Related Questions
Correct Answer is C
Explanation
This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic effect. However, this also means that the client is at a higher risk of developing toxicity or side effects from the medication.
The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inflammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.
Correct Answer is C
Explanation
The best action for the practical nurse (PN) to assist the client in dealing with his pain would be to guide the client through slow, rhythmic breathing.
Guiding the client through slow, rhythmic breathing techniques can help promote relaxation and reduce anxiety, which can indirectly contribute to pain relief. Deep breathing exercises can help the client focus on their breath and divert attention away from the pain, providing some relief and helping them cope with the discomfort. It is a non-pharmacological intervention that can be implemented immediately to help the client manage their pain.
The other options are less effective or not appropriate in this situation:
A. Dimming the lights in the room and closing the door may create a more calming environment, but it does not directly address the client's pain or provide them with effective pain relief.
B. Turning the television on to the client's favorite show may serve as a distraction, but it may not be sufficient to alleviate the client's pain.
D. Obtaining a prescription for a higher dose of pain medication should only be considered after evaluating the client's current pain management regimen and assessing their response to the current medication. It is not the immediate best action to take without further assessment and consideration of other non-pharmacological interventions.
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