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 D

Explanation

A. Substernal chest pain is a typical symptom of angina, but it is not referred pain. Angina occurs directly in the chest area and is not experienced in another location.

B. Generalized abdominal pain is common in peritonitis, but this is not referred pain. Peritonitis causes pain localized to the abdomen rather than radiating to other areas.

C. Incisional pain is postoperative pain directly related to the surgical site, not referred pain.

D. Pain in the left shoulder is a classic example of referred pain. In the case of pancreatitis, pain may be referred to the left shoulder due to irritation of the diaphragm, which shares nerve pathways with the shoulder. Referred pain occurs when pain is felt in a location other than the site of the injury or problem.

A. Raise the head of the client's bed to a 90° angle. B. Use moisturizing lotion while massaging the client's bony prominences. C. Place pillows between the client's knees when in a side-lying position. D. Instruct the client to sit on a rubber ring when seated in a chair.

Correct Answer is C

Explanation

A. Raising the head of the bed to a 90° angle is not recommended for clients with hemiplegia as it can cause discomfort and increase the risk of pressure ulcers. A semi-Fowler's position (30° to 45°) is usually more appropriate.

B. While using moisturizing lotion on bony prominences is important to prevent skin breakdown, it is not specific to the management of hemiplegia. The focus for hemiplegia is more on positioning, mobility, and preventing complications like contractures.

C. Placing pillows between the client's knees when in a side-lying position is an appropriate intervention for a client with hemiplegia. This helps maintain proper alignment of the limbs, prevents pressure sores, and reduces the risk of contractures in the affected side.

D. Instructing the client to sit on a rubber ring is generally not recommended for clients with hemiplegia, as it may not provide adequate support and can lead to improper posture or skin breakdown. Proper seating supports and positioning should be emphasized instead.

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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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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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