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).
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Related Questions
Correct Answer is D
Explanation
A change in behavior such as agitation and restlessness in a client with a traumatic brain injury can be a sign of increased intracranial pressure.
The nurse should first assess the client’s blood pressure as an increase in blood pressure can be an indicator of increased intracranial pressure.
Motor responses are not the first assessment that should be performed.
Blood glucose is not the first assessment that should be performed.
Urinary output is not the first assessment that should be performed.
Correct Answer is B
Explanation
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
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