A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?
Check the client for ecchymosis.
Initiate protective isolation for the client.
Administer ibuprofen for mild headache.
Instruct the client to shave with a disposable razor.
The Correct Answer is A
Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to thrombocytopenia. Protective isolation is generally for clients with conditions that compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with thrombocytopenia because ibuprofen can affect platelet function and potentially increase the risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a sharp blade can increase the risk of cuts and bleeding in someone with a low platelet count. Using an electric razor or avoiding shaving might be safer options to prevent injury and bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Maintaining skin integrity over the blisters is correct. Blisters form as a protective mechanism for the skin underneath. Popping or breaking blisters increases the risk of infection as it exposes the raw skin to bacteria and other contaminants.
Choice B Reason:
Applying ice to the larger blisters is incorrect.
Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin and exacerbate the injury. Ice can cause additional skin damage and can potentially increase pain and delay healing.
Choice C Reason:
Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain reliever that can help manage the discomfort caused by a minor burn. It also has anti-inflammatory properties that can reduce swelling associated with burns.
Choice D Reason:
Running cool water over the affected area is correct. Running cool (not cold) water over the burn helps to cool down the burned area, soothes the pain, and helps prevent further damage to the skin. It's recommended to run water over the burn for around 10-15 minutes to effectively cool the area.
Choice E Reason:
Allowing the affected area to remain open to air is incorrect. Keeping a minor burn uncovered can increase the risk of infection as it exposes the burn to external contaminants. Covering the burn with a sterile, non-stick dressing can protect it from further damage and reduce the risk of infection.
Correct Answer is B
Explanation
Choice A Reason:
Leaving the television on is incorrect. Constant background noise from the television might be overwhelming and confusing for someone with Alzheimer's. It's generally better to have a quiet and calming environment to reduce agitation and confusion.
Choice B Reason:
Installing locks at the top of doors is correct. This can be an essential safety measure to prevent the person from wandering or accessing unsafe areas. Installing locks higher up on doors can help prevent the individual from opening doors and wandering into potentially dangerous situations.
Choice C Reason:
Placing throw rugs on the floor is incorrect. Throw rugs pose a tripping hazard, especially for individuals with Alzheimer's who might have mobility issues or difficulties with depth perception. Removing throw rugs or securing them firmly to the floor is essential to prevent falls.
Choice D Reason:
Scheduling alternate caregivers is incorrect. While having alternate caregivers is important for support, it doesn't directly relate to environmental modifications within the home.
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