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 B

Explanation

The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.

"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.

"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.

"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.

A. "I should keep my baby rear-facing in the carseat until she is 2 years old." B. "I should position the car seat's retainer clip at the level of my baby's belly button." C. "I should enable the airbag when my baby is in the front seat of the car." D. "I should place my baby in the car seat at a 90-degree angle."

Correct Answer is A

Explanation

This statement reflects an important recommendation for car seat safety. It is recommended to keep infants and toddlers rear-facing in their car seats until they reach the age of 2 or until they outgrow the height and weight limits specified by the car seat manufacturer. Rear-facing car seats provide better protection for the child's head, neck, and spine in the event of a crash. "I should position the car seat's retainer clip at the level of my baby's belly button." The correct position for the retainer clip is at armpit level. It should be positioned across the chest, resting on the bony part of the child's shoulders. Placing the retainer clip at the level of the belly button can be unsafe and may not provide proper protection.

"I should enable the airbag when my baby is in the front seat of the car." It is not recommended to place a rear-facing car seat in the front seat of a vehicle with an active airbag. The force of the airbag deployment can cause serious injuries to the child. The safest place for a rear-facing car seat is in the back seat of the vehicle.

"I should place my baby in the car seat at a 90-degree angle." The angle at which the car seat is installed depends on the specific instructions provided by the car seat manufacturer. It is important to follow the manufacturer's guidelines for proper installation. Some car seats have built-in angle indicators or adjustable recline positions to help achieve the correct angle for optimal safety.

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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

Naxlex Comprehensive Predictor Exams

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

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