A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

Generalized rash

Elevated platelet count

Decreased total bilirubin

Hypertension

Answer and Explanation

The Correct Answer is A

A. Generalized rash is a common finding in toxic shock syndrome (TSS). The rash often appears as a sunburn-like rash and can progress to desquamation (peeling of the skin).

B. Elevated platelet count is not typically associated with toxic shock syndrome. In fact, thrombocytopenia (low platelet count) is more commonly seen in TSS.

C. Decreased total bilirubin is not associated with toxic shock syndrome. Bilirubin levels may be affected in cases of liver dysfunction, but TSS does not typically cause a decrease in bilirubin.

D. Hypertension is not a common finding in toxic shock syndrome. TSS often causes hypotension (low blood pressure) due to the systemic inflammatory response and shock.

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Correct Answer is A

Explanation

A. Respite care services provide temporary relief for caregivers, allowing them to take breaks and avoid burnout. This recommendation addresses the caregiver's fatigue and stress, helping to prevent caregiver exhaustion and improve their well-being.

B. Hospice services are appropriate for end-of-life care, but the client with moderate Alzheimer's disease is not at the end of life, so this is not the most appropriate recommendation at this stage.

C. Pursuing local protective services is necessary if there is evidence of abuse or neglect. However, the issue here seems to be caregiver stress, not abuse, so this action is not warranted.

D. Taking a nonprescription sleeping medication might address some symptoms of fatigue but does not address the underlying issue of caregiver burnout. Respite care is a more effective solution for the caregiver's needs.

A. Ask a family member to be present during the admission. B. Obtain a board that uses colored pictures as communication. C. Familiarize themselves with commonly used signed language. D. Request an interpreter during the initial assessment.

Correct Answer is D

Explanation

A. While a family member may assist in communication, it is not the most appropriate or professional option, especially if the family member may not be trained to provide accurate information or may not be fluent in sign language.

B. A board with colored pictures could be useful in some situations, but it is not the most effective or respectful way to communicate with a client who uses sign language.

C. Familiarizing oneself with commonly used sign language is helpful for general communication, but it is not sufficient for ensuring effective and accurate communication in a healthcare setting.

D. Requesting a trained interpreter is the best approach to ensure clear, accurate communication with the client. A professional interpreter can facilitate the conversation and provide the necessary support for the client’s understanding and expression of their healthcare needs.

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A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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