A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.
Wears a face mask around others
Sleeps 8 to 10 hr per night
Uses a firm bristled toothbrush
Increased intake of green, leafy vegetables
The Correct Answer is C
A. Incorrect. Wearing a face mask around others is not directly related to thrombocytopenia and does not impact the risk of injury in this context.
B. Incorrect. Sleep duration is not directly related to thrombocytopenia and does not impact the risk of injury in this context.
C. Correct. Using a firm-bristled toothbrush can increase the risk of bleeding in a client with thrombocytopenia due to potential gum injury. Soft-bristled toothbrushes are recommended to minimize the risk of injury and bleeding.
D. Incorrect. Increased intake of green, leafy vegetables is generally beneficial for health and does not increase the risk of injury in thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should identify that the client is at risk of developing heart failure and may require further assessment and intervention.
Heart failure is suggested by the progressive decline in vital signs and laboratory results, such as increasing BUN and creatinine levels, which indicate worsening kidney function and can contribute to heart failure. The client’s fatigue, weakness, bilateral edema, and crackles in the lungs are clinical signs consistent with heart failure. The dry, flaky skin and coarse, thinning hair also reflect systemic issues that could be associated with heart failure and poor nutritional status.
The nurse should focus on further assessment to evaluate the severity of heart failure and intervention to manage symptoms, potentially including medication adjustments, fluid management, and additional diagnostic testing. These steps are crucial to addressing the client’s deteriorating condition and preventing further complications.
Correct Answer is D
Explanation
A. Incorrect. The cause of death is an important piece of information but is typically included in the official death certificate rather than in routine postmortem documentation.
B. Incorrect. While vital signs are important during the client's care, the last set of vital signs is not usually a primary focus of postmortem documentation.
C. Incorrect. Advance directives are relevant to the client's care during life but are not typically included in postmortem documentation.
D. Correct. Documentation of the location of the identification tag on the client's body is important for accurate identification and tracking during the postmortem process.
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