A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?
Wears a face mask around others
Increased intake of green, leafy vegetables
Uses a firm-bristled toothbrush
Sleeps 8 to 10 hr per night
The Correct Answer is C
A. Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.
B. Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.
C. Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.
D. Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
ECT can cause temporary memory loss, particularly for events occurring around the time of the treatment. The client may experience difficulty remembering details of recent events or conversations. This effect is usually temporary and improves over time.
Neck pain is not a typical adverse reaction to ECT. The procedure itself does not involve manipulation or strain on the neck, and significant neck pain following ECT would be unusual. However, it is essential for the nurse to assess and address any discomfort or pain the client experiences after the procedure.
Voice alteration is not a known adverse reaction to ECT. ECT primarily affects the brain and does not directly impact the vocal cords or voice production.
Tingling of the scalp is not a common adverse reaction to ECT. During the procedure, the client receives a brief electrical stimulus, usually applied through electrodes placed on the scalp. Sensations experienced during the procedure are typically related to the electrical stimulation and are transient.
Correct Answer is D
Explanation
A.Having a health care proxy does not mean that the individual relinquishes their right to make their own decisions. A health care proxy is designated to make decisions on behalf of the individual when they are unable to do so, but the individual retains the right to make decisions if they are capable.
B.Having a health care proxy does not eliminate the need for a living will. A living will outline the individual's specific wishes regarding medical treatments and end-of-life care, while a health care proxy designates a person to make decisions on their behalf. Both documents serve different purposes and can work together to ensure the individual's wishes are respected.
C.A health care proxy designee is typically empowered to make medical decisions on your behalf, including signing consent forms if necessary. This is one of the primary roles of a health care proxy – to act in your best interests when you are unable to make decisions yourself, including signing forms for procedures or treatments.
D.The individual has the choice to name any person as their health care proxy designee, regardless of their relationship. It is important to choose someone who understands the individual's wishes and can make decisions in their best interest. The decision of whom to name as the health care proxy designee is personal and should be based on trust and understanding.
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