A nurse receives report on a client who is diagnosed with thrombotic thrombocytopenic purpura (TTP). Understanding the complications associated with this condition, which assessment is the priority for the nurse to complete for this client?
Assess pedal pulses
Assess nutritional status
Assess urine output
Assess liver function
The Correct Answer is C
A. While assessing pedal pulses is important for circulation and can indicate peripheral vascular status, it is not the highest priority compared to assessing renal function in a client with TTP.
B. Nutritional status is important for overall health and recovery but is not immediately critical compared to assessing for acute complications such as kidney damage in TTP.
C. TTP can lead to kidney damage due to the formation of clots in the small blood vessels of the kidneys. This can result in decreased urine output or even acute kidney injury (AKI). Monitoring urine output is crucial to assess renal function and detect early signs of kidney involvement.
D. TTP primarily affects the kidneys and blood coagulation system, leading to hemolysis and thrombocytopenia. Liver function is not typically a primary concern in TTP unless there are concurrent issues or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This option is appropriate because the client's low white blood cell count (3,100/mm³) suggests they are at risk for infection due to chemotherapy-induced immunosuppression. Using an electric shaver reduces the risk of cuts and nicks that could potentially lead to infections.
B. This option is not necessary based on the client's current lab results. Negative pressure isolation rooms are typically reserved for clients with severely compromised immune systems, such as those with very low neutrophil counts (neutropenia). A white blood cell count of 3,100/mm³ is within a range where standard precautions are usually sufficient.
C. This option addresses food safety precautions for clients with neutropenia (low white blood cell count). Raw vegetables, including salads, have a higher risk of harboring bacteria that could cause infections. Therefore, cooked vegetables are safer for clients with compromised immune systems.
D. This option is appropriate because chemotherapy-induced thrombocytopenia (low platelet count of 280,000/mm³) increases the risk of bleeding. Forceful blowing of the nose can traumatize the nasal mucosa and increase the risk of nosebleeds. Dabbing the nose gently is a safer method to avoid nosebleeds.
Correct Answer is C
Explanation
A. Involves the use of physical force that may result in bodily injury, pain, or impairment. This option does not fit the scenario described because it does not involve direct physical harm.
B. Involves behaviors such as intimidation, threats, humiliation, and isolation that cause mental or emotional distress. While similar to neglect in some aspects, neglect specifically refers to the failure to provide essential care rather than actively causing psychological harm.
C. Neglect refers to the failure of a caregiver or responsible person to provide the necessary care, assistance, or supervision that is essential to maintain the health and well-being of an elderly person.
D. Involves unauthorized or improper use of an elderly person's financial resources. This option does not apply to the scenario described as it involves financial exploitation rather than the physical or emotional neglect of the resident.
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