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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?

A.

Generalized rash

B.

Elevated platelet count

C.

Decreased total bilirubin

D.

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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Related Questions

Correct Answer is C

Explanation

A. Increasing the room temperature may be necessary to prevent hypothermia, but the priority after securing the airway is fluid resuscitation to prevent shock and maintain circulation.

B. Administering analgesic medication is important for pain management but should not be the first intervention. Fluid resuscitation is the priority to stabilize the client’s condition.

C. The first priority in burn care after securing the airway is to start an IV with a large-bore needle to initiate fluid resuscitation. Burn victims are at high risk for fluid loss and hypovolemic shock, so IV fluids are crucial to maintain circulation and prevent organ failure.

D. Cleansing the wounds is important but should be done after stabilizing the client’s condition, particularly after fluid resuscitation.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Rationale

Interpretation of Findings:

  • Productive cough:
    • Unrelated to diagnosis
      A productive cough is not directly related to cirrhosis. It may indicate a respiratory issue, but it does not directly reflect the progression or improvement of the client's liver condition.
  • Spontaneous bruising:
    • Indication of potential worsening condition
      Spontaneous bruising suggests a decline in clotting function, which is common in advanced cirrhosis due to impaired liver synthesis of clotting factors.
  • Hematemesis:
    • Indication of potential worsening condition
      Hematemesis indicates gastrointestinal bleeding, which could result from esophageal varices or other complications of portal hypertension, a severe complication of cirrhosis.
  • Ascites:
    • Indication of potential worsening condition
      Ascites reflects worsening fluid retention and portal hypertension, indicating the progression of cirrhosis.
  • Increased albumin level:
    • Indication of potential improvement
      An increased albumin level suggests improved liver synthetic function or nutritional status, which is a positive sign in a client with cirrhosis.
  • Elevated iron:
    • Unrelated to diagnosis
      Elevated iron levels are associated with the client's history of hemochromatosis but are not directly indicative of the progression or improvement of cirrhosis in this context.

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