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

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.

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Correct Answer is D

Explanation

Wearing shoes with rubber soles can minimize noise and provide a quieter environment for the clients. It helps reduce disruptions caused by footsteps, especially during nighttime when clients are trying to sleep.

Conducting change-of-shift report near the clients' rooms can lead to increased noise levels and disturb clients' sleep. It is best to conduct report in a designated area away from patient rooms to minimize disruptions.

Overhead lights should be avoided during nighttime or sleep hours as they are bright and can disrupt a client's sleep. Instead, nurses should use a low-intensity light or a flashlight to check IV lines or attend to other needs. This helps minimize disruptions to the client's rest.

Opening curtains between clients in semiprivate rooms can compromise privacy and contribute to increased noise levels. It is important to provide privacy for clients, especially during their rest periods.

A. Beefy, red tongue B. Facial erythema C. Fever D. Peeling of the hands and feet

Correct Answer is C

Explanation

When collecting data from a child with pertussis (whooping cough), the nurse should expect the following manifestations:

Paroxysmal cough: The hallmark symptom of pertussis is a severe, uncontrollable cough that often occurs in bursts (paroxysms) followed by a characteristic "whooping" sound as the child inhales.
Posttussive vomiting: The coughing spells can be so severe that they may lead to vomiting.
Inspiratory whoop: As mentioned earlier, during the inhalation phase after a coughing episode, the child may make a distinctive whooping sound.
Cyanosis: The prolonged coughing episodes can sometimes cause the child's face to turn blue (cyanosis) due to inadequate oxygen intake.
Fatigue and exhaustion: The frequent and intense coughing episodes can be exhausting for the child, leading to fatigue and sleep disturbances.

Other possible manifestations of pertussis can include a mild fever, runny nose, and sneezing. However, these symptoms are less specific to pertussis and can be seen in other respiratory infections as well.

The manifestations listed in the question (beefy, red tongue; facial erythema; peeling of the hands and feet) are not typically associated with pertussis and may be indicative of other conditions or diseases. It is important to consult a healthcare provider for a proper evaluation and diagnosis.

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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 in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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