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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Experiences nocturia is incorrect. Nocturia (waking up at night to urinate) is a common symptom and, while it's important to address for the client's comfort and potential underlying causes, it doesn't pose an immediate risk to the client's roommate or necessitate urgent intervention in a shared room setting.
Choice B Reason:
History of generalized anxiety disorder is incorrect. A history of generalized anxiety disorder is relevant to the client's mental health and overall care. However, in the context of a shared room, it might not require immediate attention or interventions that directly impact the roommate's health or safety.
Choice C Reason:
Recent exposure to tuberculosis is correct. Tuberculosis (TB) is an infectious disease that spreads through the air when an infected person coughs or sneezes. In a shared room, a history of recent exposure to TB is a significant concern as it poses a potential risk to both the client and the roommate. Immediate measures to prevent transmission and ensure proper isolation protocols are necessary to protect the health of both individuals in the shared space.
Choice D Reason:
Reports periodic migraine headaches is correct.
Periodic migraine headaches are a health concern for the client experiencing them, but they typically do not pose an immediate risk or concern for the client's roommate. While addressing pain management is important, it might not require immediate action in the shared room environment.
Correct Answer is D
Explanation
Choice A Reason:
Age 45 years is incorrect. While age is a significant factor in osteoporosis risk, 45 years old isn't inherently considered a high-risk age for developing osteoporosis. However, bone density tends to decrease gradually with age, and after menopause in women, there's a more significant decline due to hormonal changes.
Choice B Reason:
Regular aerobic exercise is incorrect. Regular exercise, particularly weight-bearing and muscle-strengthening activities, is typically beneficial for bone health. It can help maintain or improve bone density and strength, reducing the risk of osteoporosis. Therefore, regular aerobic exercise is generally considered a protective factor against osteoporosis, rather than a risk factor.
Choice C Reason:
Uses NSAIDs for pain relief is incorrect. While long-term use of certain medications, such as glucocorticoids (steroids), can increase the risk of osteoporosis due to their impact on bone density, the use of NSAIDs (nonsteroidal anti-inflammatory drugs) for pain relief isn't directly linked to osteoporosis as a significant risk factor. However, chronic use of certain medications might have implications for bone health and should be assessed on an individual basis.
Choice D Reason:
Smoking is a known risk factor for osteoporosis. It can have detrimental effects on bone health by interfering with the body's ability to absorb calcium, decreasing estrogen levels, and impairing bone-forming cells. Consequently, smokers have a higher risk of developing osteoporosis compared to non-smokers.
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