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

Answer and Explanation

The Correct Answer is C

Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired blood clotting and an increased risk of bleeding. The use of a firm-bristled toothbrush can cause trauma to the gums and oral tissues, increasing the risk of bleeding in someone with thrombocytopenia. It is recommended for individuals with thrombocytopenia to use a soft-bristled toothbrush to minimize the risk of oral bleeding.

Wearing a face mask around others, increased intake of green, leafy vegetables, and getting an adequate amount of sleep do not directly increase the client's risk for injury in the context of thrombocytopenia. These practices are generally beneficial for overall health and well-being.

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Correct Answer is C

Explanation

a.Applying the restraint under the client's clothes: Restraints should be applied over the client's clothes to avoid direct skin contact and reduce the risk of skin irritation or injury.

b.Tying the restraint to the railing of the client's bed: Restraints should not be tied to bed rails or any other fixed objects. This can increase the risk of injury to the client and should be avoided.

c.Placing the client in a sitting position is appropriate when applying a belt restraint, as it helps prevent respiratory compromise and allows the client to maintain a safer and more comfortable posture.

d.A belt restraint should be placed around the client's waist, not across the chest, to avoid restricting breathing.

A. Administer an oral contrast solution B. Ensure that the client gave informed consent C. Inform the client the procedure will take 60 min D. Ensure that the client's bladder is full

Correct Answer is B

Explanation

Before any invasive procedure, it is essential to ensure that the client has given informed consent. Informed consent involves providing the client with detailed information about the procedure, its risks and benefits, and alternatives. The client should have the opportunity to ask questions and fully understand the procedure before giving consent.

Oral contrast solutions are typically used for imaging procedures such as CT scans or X-rays, not for esophagogastroduodenoscopy. This procedure involves the insertion of a flexible tube with a camera into the esophagus, stomach, and duodenum to visualize the upper gastrointestinal tract.

While it is important to provide the client with information about the duration of the procedure, stating a specific time frame may not be accurate or helpful. The duration of an esophagogastroduodenoscopy can vary depending on factors such as the complexity of the procedure and the client's individual circumstances.

Having a full bladder is not necessary for an esophagogastroduodenoscopy procedure. This requirement may be relevant for other procedures, such as pelvic ultrasound, but it is not applicable in this case.

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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?

Nursing Test Bank

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