A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

Generalized rash

Elevated platelet count

Decreased total bilirubin

Hypertension

Answer and Explanation

The Correct Answer is A

A. Generalized rash is a common finding in toxic shock syndrome (TSS). The rash often appears as a sunburn-like rash and can progress to desquamation (peeling of the skin).

B. Elevated platelet count is not typically associated with toxic shock syndrome. In fact, thrombocytopenia (low platelet count) is more commonly seen in TSS.

C. Decreased total bilirubin is not associated with toxic shock syndrome. Bilirubin levels may be affected in cases of liver dysfunction, but TSS does not typically cause a decrease in bilirubin.

D. Hypertension is not a common finding in toxic shock syndrome. TSS often causes hypotension (low blood pressure) due to the systemic inflammatory response and shock.

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Correct Answer is C

Explanation

A. Limiting fluid intake is not appropriate for preventing venous thromboembolism (VTE). Adequate hydration is important to maintain blood volume and prevent clot formation.

B. Massaging the client's legs is not recommended, as it can dislodge a clot if one is present, increasing the risk of embolism.

C. Encouraging circumduction of the feet (circular motion of the feet) helps improve circulation and prevent venous stasis, which is a key factor in the development of venous thromboembolism.

D. Keeping the client's knees in a flexed position can increase the risk of venous stasis and clot formation. The client should be encouraged to keep their legs straight and perform exercises to promote circulation.

A. Anticipate client to be prepped for cardiac catheterization. B. Assist with a continuous heparin infusion. C. Encourage the client to ambulate. D. Anticipate an increased dosage of metoprolol. E. Obtain a prescription for client to be NPO. F. Request a prescription for an antibiotic.

Correct Answer is ["A"]

Explanation

A. Anticipate client to be prepped for cardiac catheterization.
The client is presenting with signs and symptoms indicative of acute myocardial infarction (MI), including chest pain radiating to the left arm, nausea, diaphoresis, tachycardia, and abnormal diagnostic results such as elevated troponin and myoglobin levels. The 12-lead electrocardiogram (ECG) showing ST segment elevation and T wave changes is also suggestive of an acute MI. Cardiac catheterization is commonly used to diagnose and treat acute coronary syndrome, particularly if there is a suspicion of a blockage in the coronary arteries. This is the most appropriate intervention at this time.
B. Assist with a continuous heparin infusion.
Heparin is often used in the management of acute coronary syndrome to prevent further clot formation. However, it is not the first action the nurse should take without a provider's prescription. Heparin may be indicated depending on the clinical scenario and provider's orders, but it should not be administered without a specific prescription.
C. Encourage the client to ambulate.
Encouraging ambulation is contraindicated in this situation. The client is likely experiencing an acute MI, and ambulation could increase myocardial oxygen demand, worsening the condition. Rest and monitoring are essential in this phase of care.
D. Anticipate an increased dosage of metoprolol.
Metoprolol is a beta-blocker that may be used to control heart rate and reduce myocardial oxygen demand in the setting of an MI. However, the dosage adjustment should be based on the provider's orders and the client's hemodynamic status. The nurse should monitor the client closely for signs of bradycardia or hypotension, which could necessitate adjusting the dosage, but this is not the immediate action.
E. Obtain a prescription for client to be NPO.
The client is likely to require diagnostic tests and possibly interventions such as cardiac catheterization or surgery. In preparation for these procedures, the client should be NPO (nothing by mouth) to reduce the risk of aspiration and to ensure that the client is ready for potential interventions. However, this is not the first action but should be anticipated soon after assessment.
F. Request a prescription for an antibiotic.
An antibiotic is not indicated at this time as there is no evidence of infection in the client's presentation. The focus should be on managing the acute myocardial infarction, not treating an infection.

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