A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

Wears a face mask around others

Sleeps 8 to 10 hr per night

Uses a firm bristled toothbrush

Increased intake of green, leafy vegetables

Answer and Explanation

The Correct Answer is C

A.   Incorrect. Wearing a face mask around others is not directly related to thrombocytopenia and does not impact the risk of injury in this context.
B.   Incorrect. Sleep duration is not directly related to thrombocytopenia and does not impact the risk of injury in this context.
C.   Correct. Using a firm-bristled toothbrush can increase the risk of bleeding in a client with thrombocytopenia due to potential gum injury. Soft-bristled toothbrushes are recommended to minimize the risk of injury and bleeding.
D.   Incorrect. Increased intake of green, leafy vegetables is generally beneficial for health and does not increase the risk of injury in thrombocytopenia.

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Correct Answer is B

Explanation

A. Incorrect. The closure of the posterior fontanel by 23 months is a normal developmental milestone.
B. Correct. The anterior fontanel typically closes by 12 to 18 months of age. If it closes prematurely, it could be a sign of craniosynostosis and should be assessed by the provider.
C. Incorrect. Rolling from the back to the abdomen is a normal developmental milestone at around 46 months of age.
D. Incorrect. Moving objects to the mouth is a normal developmental behavior in infants as they explore their environment through sensory input.

A. Assists the client to the bathroom every 2 hr B. Locks the wheels on the client's bed C. Raises all four side rails on the client's bed D. Clears furniture from the path leading to the bathroom

Correct Answer is C

Explanation

A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.

B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.

C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.

D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.

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A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

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Naxlex Comprehensive Predictor Exams

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