A nurse is caring for a patient diagnosed with thrombocytopenia. Which of the following interventions should the nurse prioritize to ensure the safety of the patient?
Encourage the patient to engage in strenuous exercise to improve circulation
Instruct the patient to use an electric razor for shaving
Teach the patient to use a water pick for oral hygiene
Request an order for subcutaneous heparin to prevent blood clots
The Correct Answer is B
Choice A reason: Encouraging the patient to engage in strenuous exercise to improve circulation is not appropriate for someone with thrombocytopenia. Strenuous exercise can increase the risk of injury and bleeding, which is particularly dangerous for patients with a low platelet count.
Choice B reason: Instructing the patient to use an electric razor for shaving is the most appropriate intervention. Thrombocytopenia increases the risk of bleeding, and using an electric razor instead of a traditional blade helps minimize the risk of cuts and subsequent bleeding.
Choice C reason: Teaching the patient to use a water pick for oral hygiene is not recommended for thrombocytopenia patients. Water picks can cause bleeding of the gums, which is a concern for individuals with low platelet counts. Using a soft-bristled toothbrush is safer.
Choice D reason: Requesting an order for subcutaneous heparin to prevent blood clots is not advisable for a thrombocytopenia patient without specific medical indication. Heparin is an anticoagulant, and administering it to someone with low platelets can exacerbate the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hypertension, often called the "silent killer," is usually asymptomatic until significant target organ damage has occurred. This means that many people with hypertension do not experience symptoms until their blood pressure has been high for a long time, leading to damage in organs such as the heart, kidneys, brain, and eyes. Therefore, it's crucial for patients to understand the importance of regular blood pressure monitoring and management even in the absence of symptoms.
Choice B reason: While annual BP checks are useful for monitoring treatment effectiveness, more frequent monitoring may be necessary for newly diagnosed patients or those with poorly controlled hypertension. This information is important but not the most critical point compared to understanding the asymptomatic nature of hypertension.
Choice C reason: Increasing physical activity can help control blood pressure for many individuals, but it is not universally effective for everyone. While important, this information is part of a broader lifestyle modification plan rather than the single most critical point to emphasize.
Choice D reason: Dietary changes can play a significant role in controlling blood pressure, but not all individuals can control their BP through diet alone. Emphasizing this may give a false sense of control without highlighting the importance of medication and other interventions when needed.
Correct Answer is B
Explanation
Choice A reason: Kidney failure is not a common immediate complication related to the patient's presentation of sudden right-sided weakness and difficulty speaking, which are indicative of a stroke. Although diabetes and hypertension can eventually lead to kidney issues, this is not an acute complication.
Choice B reason: Aspiration pneumonia is a potential complication of the patient's condition, especially given the presence of expressive aphasia. Patients with neurological deficits, particularly those affecting speech and swallowing, are at higher risk of aspirating food or liquids into the lungs, leading to pneumonia.
Choice C reason: Hypotension is not commonly a direct complication of a stroke, especially considering the patient's elevated blood pressure. Stroke patients often present with hypertension rather than hypotension.
Choice D reason: Heart failure, while related to the patient's underlying conditions like hypertension and possibly diabetes, is not an immediate complication of the acute neurological event described. The focus should be more on the neurological and respiratory complications.
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