A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Check the client for ecchymosis.

Initiate protective isolation for the client.

Administer ibuprofen for mild headache.

Instruct the client to shave with a disposable razor.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to thrombocytopenia. Protective isolation is generally for clients with conditions that compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with thrombocytopenia because ibuprofen can affect platelet function and potentially increase the risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a sharp blade can increase the risk of cuts and bleeding in someone with a low platelet count. Using an electric razor or avoiding shaving might be safer options to prevent injury and bleeding.

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Correct Answer is D

Explanation

Choice A Reason:

"Having a total cholesterol level below 200 mg/dl increases my risk for a stroke." This statement is incorrect. Generally, having a total cholesterol level below 200 mg/dl is considered beneficial for heart health and reducing the risk of stroke.

Choice B Reason:

"My risk for a stroke increases if my HbA1c level is 6 percent or less." This statement is incorrect. An HbA1c level of 6 percent or less is an indicator of good blood sugar control, which usually reduces the risk of stroke. A higher HbA1c level is associated with an increased risk of complications in diabetes, including stroke.

Choice C Reason:

"My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." - Glucocorticoids are not typically prescribed to reduce the risk of stroke in individuals with diabetes. These medications may have various uses but are not a standard preventive measure for stroke in this context.

Choice D Reason:

"I can decrease my risk for a stroke by losing excess weight." This statement is appropriate. Maintaining a healthy weight is a significant factor in reducing the risk of stroke, especially for individuals with diabetes. Weight management contributes to better control of blood pressure, cholesterol levels, and blood sugar, which collectively reduce the risk of stroke.

A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL) B. Aspartate aminotransferase 34 units/L (0 to 34 units/L) C. Ammonia 55 mcg/dl. (10 to 80 mcg/dL) D. Platelets 60,000/mm3 (150,000 to 400,000/mm3)

Correct Answer is D

Explanation

Choice A Reason:

Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL) is incorrect. Bilirubin levels within the normal range typically indicate normal liver function. The value of 1.0 mg/dL falls within the expected range, so it doesn't raise immediate concerns regarding the need for a liver biopsy.

Choice B Reason:

Aspartate aminotransferase 34 units/L (0 to 34 units/L) is incorrect. Aspartate aminotransferase (AST) is an enzyme found in various tissues, including the liver, heart, muscles, and red blood cells. While a value of 34 units/L is at the upper limit of the normal range, it's still within the expected range and doesn't typically prompt immediate concern for the need for a biopsy.

Choice C Reason:

Ammonia 55 mcg/dL (10 to 80 mcg/dL ) is incorrect. Ammonia levels can rise in cases of liver dysfunction. The level of 55 mcg/dL falls within the reference range, indicating normal or near-normal ammonia levels, which doesn't usually necessitate an urgent liver biopsy.

Choice D Reason:

Platelets 60,000/mm3 (150,000 to 400,000/mm3) is correct. Platelets are crucial for blood clotting. A significantly low platelet count, such as 60,000/mm3, termed thrombocytopenia, can indicate compromised clotting ability, which might pose a risk of bleeding during or after a liver biopsy. In the context of a liver biopsy, a low platelet count warrants attention and consideration before proceeding with the procedure to prevent excessive bleeding or complications.

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A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

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