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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:

Ensure the blinds in the client's room remain open is not appropriate. Bright light can contribute to sensory overload. It's better to create a subdued and calming environment, so keeping the blinds closed or partially closed might help reduce excess stimuli.

Choice B Reason:

Place the client in a room near the nurses' station is not appropriate. Being near the nurses' station could increase the noise and activity around the client, potentially worsening sensory overload. It's advisable to place the client in a quieter area away from high-traffic zones to minimize auditory and visual stimulation.

Choice C Reason:

Play quiet music in the client's room is incorrect. While soothing music might help some individuals relax, for someone experiencing sensory overload, even low-volume music could add to the stimuli. Silence or minimal ambient noise might be more beneficial.

Choice D Reason:

Break up nursing care into small, frequent sessions is correct. This action is beneficial for managing sensory overload. Breaking up care into smaller sessions allows for adequate rest periods between activities, reducing the overall sensory input at any given time.

A. Keep both arms below the level of the client's heart. B. Limit range-of-motion exercises with the affected arm. C. Use the client's left arm to obtain blood samples. D. Obtain blood pressure readings using the client's right arm.

Correct Answer is C

Explanation

Choice A Reason:

Keeping both arms below the level of the client's heart doesn't specifically address the prevention of lymphedema and might not be necessary for this purpose.

Choice B Reason:

Limiting range-of-motion exercises with the affected arm could potentially contribute to stiffness and reduced function, but appropriate and gradual range-of-motion exercises are generally recommended to prevent lymphedema.

Choice C Reason:

Using the client's left arm to obtain blood samples is correct. Lymphedema can occur due to the disruption of lymphatic vessels during surgery, leading to the accumulation of lymph fluid. To reduce the risk of lymphedema, medical procedures or blood draws should typically avoid using the affected arm. In this case, after a right radical mastectomy, using the left arm for blood samples can help protect the compromised lymphatic system in the right arm.

Choice D Reason:

Obtaining blood pressure readings using the client's right arm is not directly related to preventing lymphedema. However, excessive pressure or trauma to the affected arm should generally be avoided to reduce the risk of lymphedema.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Correct Answer is C

Explanation

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