A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:

Fatigue

Side effects of immunosuppressants

Thrombocytopenia

Infection

Answer and Explanation

The Correct Answer is C

Choice A reason: Fatigue is a common symptom of ITP but is not the primary concern for monitoring, as it does not directly indicate the severity of the condition.

Choice B reason: While monitoring for side effects of immunosuppressants is important, it is not the priority concern. The primary issue in ITP is the low platelet count, which poses a risk of bleeding.

Choice C reason: Thrombocytopenia, or low platelet count, is the hallmark of ITP and the main concern for monitoring, as it increases the risk of bleeding and bruising.

Choice D reason: Infection is a risk due to the potential use of immunosuppressants in treatment; however, the immediate concern in ITP management is the platelet count and associated bleeding risk.

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Correct Answer is D

Explanation

Choice A reason: This choice is incorrect. A stroke involving the right cerebral hemisphere typically affects the left side of the body and can cause problems with spatial and perceptual abilities, not necessarily with language or discrimination of words and letters, which are more commonly associated with left hemisphere strokes⁸.

Choice B reason: Motor retardation is not specific to right hemisphere strokes. While right hemisphere strokes can cause weakness on the left side of the body, the term 'motor retardation' is not commonly used to describe this symptom⁸.

Choice C reason: This choice is incorrect because deficits in the right visual field would suggest a problem with the left cerebral hemisphere, not the right. A right hemisphere stroke typically causes problems with the left visual field⁸.

Choice D reason: This is the correct choice. Individuals with right hemisphere strokes may exhibit poor impulse control, as the right hemisphere is involved in judgment and behavior regulation⁸.

A. Offer the client the bedpan every 2 hours. B. Cleanse the perineum from front to back. C. Encourage fluid intake at and between meals. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.

Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.

Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.

Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.

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A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is D

Explanation

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

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