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
Explanation
A. Turn cellular phones to silent mode
Staff members should be advised to silence their cellular phones during an active shooter situation. This helps maintain silence and prevents the ringing or vibrating of phones from potentially revealing the location of individuals hiding or seeking shelter.
Move wounded clients to a safe area before finding shelter in (option B) is not correct. In the event of an active shooter situation. The safety of both staff members and clients is paramount. If it can be done quickly and without putting oneself or others at significant risk, moving wounded clients to a safe area before finding shelter may be advisable. However, the primary focus should be on finding shelter and protecting oneself from harm.
Attempt to bargain with the shooter in (option C) is not correct. Engaging in negotiations or attempting to reason with an active shooter can be extremely dangerous and may escalate the situation. Staff members should be instructed to prioritize their own safety and follow established active shooter protocols, which often involve evacuating, hiding, or acting to incapacitate or disable the shooter as a last resort.
Wave hands to attract the attention of law enforcement in (option D) is not correct. Waving hands or making sudden movements that may be misconstrued as threatening can potentially result in harm or confusion when law enforcement or security personnel are responding to an active shooter situation. It is important to follow their instructions calmly and clearly, keeping hands visible and following their guidance to ensure everyone's safety.
In summary, the nurse should recommend turning cellular phones to silent mode, moving wounded clients to a safe area if possible, not attempting to bargain with the shooter, and avoiding actions that may be misinterpreted by law enforcement. These recommendations are aimed at prioritizing personal safety and following established protocols to minimize risks during an active shooter situation.
Correct Answer is C
Explanation
Regular physical exercise has been shown to promote better sleep. Engaging in daily exercise can help regulate the sleep-wake cycle, promote relaxation, reduce anxiety and stress, and increase overall sleep quality. It is important to note that exercise should ideally be done earlier in the day, at least a few hours before bedtime, as exercising too close to bedtime may actually have a stimulating effect and make it harder to fall asleep.
The other options listed are not the most appropriate recommendations for addressing difficulty in falling asleep:
- "Sleep longer hours on the weekend." This suggestion may disrupt the client's sleep routine and can lead to inconsistent sleep patterns throughout the week, potentially making it more challenging to fall asleep on subsequent nights.
- "Keep the television volume low while you are trying to fall asleep." It is generally recommended to create a sleep-friendly environment, which includes reducing external stimuli like noise, light, and electronic devices in the bedroom. However, watching television right before bedtime can interfere with sleep as the bright light and stimulating content can keep the mind awake.
- "Remain in bed until you fall asleep." This recommendation may contribute to increased frustration and anxiety if the client is unable to fall asleep quickly. It is generally advised to practice good sleep hygiene, which includes getting out of bed if unable to fall asleep after a reasonable amount of time and engaging in a relaxing activity until feeling sleepy again.
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