A nurse is caring for a client who presents with unexplained bruising and fatigue. The client is a 30-year-old female who reports a recent increase in menstrual bleeding, During the assessment, the nurse notes that the client has petechiae on her lower extremities.
Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.
The Correct Answer is []
Rationale:
The client’s symptoms of petechiae, easy bruising, fatigue, and increased menstrual bleeding are classic findings of thrombocytopenia, particularly immune thrombocytopenia, which involves immune-mediated platelet destruction. The absence of abnormal vital signs supports a hematologic disorder rather than an acute infectious or shock state.
Initiating bleeding precautions is essential because low platelet levels significantly increase the risk of spontaneous bleeding. Administering immunoglobulins helps reduce platelet destruction by modulating the immune response and is a standard treatment for immune thrombocytopenia.
Monitoring platelet counts provides a direct measure of disease severity and response to therapy. Observing for signs of bruising or bleeding helps evaluate clinical progression and detect complications early, ensuring timely intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. This option includes some general indicators of discomfort (crying, feeding, mobility), but it does not reflect the standardized components of the FLACC scale. Sleep patterns and feeding habits are not part of the tool. Therefore, this is incorrect.
B. While facial expression and vocalization are relevant, this option incorrectly includes physiological parameters such as heart rate, blood pressure, and temperature. The FLACC scale is a behavioral pain assessment tool, not a physiological one, so this option is incorrect.
C. The FLACC scale stands for Face, Legs, Activity, Cry, Consolability. This option correctly lists all five components used to assess pain in young children who cannot verbalize their pain. Therefore, this is the correct answer.
D. Although leg movement and behavioral changes may relate to pain, parental report and hydration status are not components of the FLACC scale. This option does not accurately reflect the standardized tool, making it incorrect.
Correct Answer is D
Explanation
Rationale:
A. NSAIDs can increase the risk of methotrexate toxicity by reducing renal clearance, which may lead to dangerous accumulation and increased risk of liver or bone marrow toxicity. Clients are advised to consult their provider before taking any over-the-counter medications.
B. Methotrexate inhibits folate metabolism, which is why folic acid supplementation is often prescribed. However, dietary folate alone is insufficient to prevent toxicity, and clients should follow prescribed folic acid supplementation rather than relying solely on diet.
C. Some vitamins and supplements, especially those containing high doses of folic acid, iron, or other interacting compounds, may interfere with methotrexate’s effectiveness or toxicity profile. Clients should confirm all supplements with their provider.
D. Methotrexate can cause hepatotoxicity, and alcohol consumption further increases this risk. Avoiding alcohol is a key teaching point to minimize liver damage while on therapy.
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