A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements Indicates an understanding of the teaching?
"I will wipe my nose instead of blowing it."
"I will remove my shoes when I'm inside my house."
"I will use an enema to manage my constipation."
"I will floss between my teeth every time I brush."
The Correct Answer is A
A. Wiping the nose instead of blowing it reduces the risk of trauma to the nasal mucosa, which can lead to bleeding, especially in individuals with thrombocytopenia.
B. Removing shoes inside the house is a general hygiene practice and does not specifically address the risk of bleeding associated with thrombocytopenia.
C. Using an enema to manage constipation is unrelated to thrombocytopenia and may not be indicated without further assessment and guidance from healthcare providers.
D. While oral hygiene is important, flossing may increase the risk of gum bleeding in individuals with thrombocytopenia, and its frequency should be discussed with healthcare providers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Hypertension is not a typical complication following an amniocentesis; it's more commonly associated with conditions like preeclampsia.
B: Amniocentesis can sometimes trigger premature labor, so monitoring for contractions is essential.
C: Epigastric pain is not a common complication of amniocentesis and may be indicative of other issues such as gastrointestinal problems.
D: Vomiting is not typically associated with amniocentesis, although it can occur due to stress or other factors unrelated to the procedure.
Correct Answer is ["B","C","D","G","H"]
Explanation
A. Contact precautions are not indicated based on the assessment findings provided. Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.
C. Reducing stimuli, such as bright lights and loud noises, can lower the risk of seizures in clients with preeclampsia.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Internal fetal monitoring is typically used during labor to provide a more accurate reading of the baby's heart rate. It involves guiding a thin wire through the cervix and attaching it to the baby's scalp. At 30 weeks gestation, internal monitoring would not be standard practice as it is invasive and labor has not yet commenced.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.
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