A nurse is caring for a female client who has toxic shock syndrome.
Which of the following findings should the nurse expect?
Elevated platelet count.
Decreased total bilirubin.
Hypertension.
Generalized rash.
The Correct Answer is D

Toxic shock syndrome (TSS) is a life-threatening condition caused by bacterial toxins.
Common symptoms include high fever, low blood pressure, headache, rapid heartbeat, nausea and vomiting, muscle pain, malaise, confusion, and rashes on the soles and palms.
A generalized rash resembling a sunburn is one of the possible signs and symptoms of TSS.
A. Elevated platelet count: TSS does not cause an elevated platelet count.
B. Decreased total bilirubin: TSS does not cause a decrease in total bilirubin levels.
C. Hypertension: TSS causes low blood pressure (hypotension), not high blood pressure (hypertension).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.

Correct Answer is A
Explanation
Acupuncture is commonly used to treat a wide range of illnesses and ailments including pain management, control of nausea and vomiting, fatigue, hot flashes, xerostomia, neuropathy, anxiety, depression, and sleep disturbance in cancer patients.
However, I could not find any information that suggests mouth sores (B), headaches, or urticaria (D) are contraindications for acupuncture.
Lymphedema is a contraindication for acupuncture because it can increase the risk of infection in the affected area.
It is important for the nurse to identify this as a contraindication to receiving acupuncture therapy.

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