A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

Determine the client's blood type.

Institute bleeding precautions.

Avoid administering IV pain medication.

Implement airborne precautions.

Answer and Explanation

The Correct Answer is B

B. Petechiae indicate a risk of bleeding due to low platelet levels or dysfunction. Bleeding precautions aim to minimize the risk of injury and bleeding events.

A While knowing the blood type is generally important for medical management, it is not the immediate priority based on the presence of petechiae alone.

C. Intravenous pain medications, especially those that can affect platelet function (like NSAIDs), may increase the risk of bleeding.

D. Airborne precautions are used for diseases transmitted by airborne droplets smaller than 5 microns, such as tuberculosis or measles. Petechiae are not indicative of an airborne disease transmission risk.

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Correct Answer is C

Explanation

C. An increase in uric acid levels (hyperuricemia) is a hallmark finding in acute gout. Elevated uric acid levels predispose to the formation and deposition of urate crystals in joints, leading to the inflammatory response seen in gout attacks.

A While CK levels can increase in conditions affecting muscles (like rhabdomyolysis), it is not specifically associated with acute gout.

C Uric acid levels are typically elevated during acute gout attacks. This is because gout results from the deposition of urate crystals in the joints due to elevated serum uric acid levels. Therefore, during an acute gout attack, uric acid levels in the blood are often higher than normal.

D. Chloride is an electrolyte and its levels can vary based on hydration status, acid-base balance, and kidney function. It is not directly associated with acute gout, so its levels would not necessarily increase in this condition.

A. Bradycardia B. Photophobia C. Petechiae on the chest D. Intermittent headache

Correct Answer is B

Explanation

B. Photophobia, or sensitivity to light, is a common symptom in clients with meningitis. It occurs due to irritation of the meninges and the optic nerve by the inflammatory process. Clients may avoid bright lights and prefer dimly lit environments to reduce discomfort.

A Bradycardia (slow heart rate) is not typically associated with meningitis. In fact, many clients with meningitis may present with tachycardia (fast heart rate) due to fever, dehydration, and systemic inflammation. Therefore, bradycardia is not an expected finding in meningitis.

C. Petechiae (small red or purple spots) on the chest can occur in bacterial meningitis, particularly in cases caused by Neisseria meningitidis. These petechiae are often seen in clusters and can indicate disseminated intravascular coagulation (DIC), a serious complication associated with meningococcal infection. However, they are less specific

D. Headache is a hallmark symptom of meningitis, typically described as severe and persistent. It is often accompanied by other symptoms such as fever, neck stiffness (nuchal rigidity), photophobia, and altered mental status. Headache in meningitis is usually continuous rather than intermittent.

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A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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