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

Wears a face mask around others

Increased intake of green, leafy vegetables

Uses a firm-bristled toothbrush

Sleeps 8 to 10 hr per night

Answer and Explanation

The Correct Answer is C

A. Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.

B. Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.

C. Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.

D. Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.

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Correct Answer is B

Explanation

Bran muffins are a good choice for relieving constipation because they are high in dietary fiber. Fiber adds bulk to the stool and helps promote regular bowel movements. It can soften the stool, making it easier to pass.

Puffed rice cereal is a low-fiber food and may not provide significant relief for constipation. It is typically low in fiber and may not help in promoting regular bowel movements.

Tomato juice, while a healthy choice, is not particularly high in fiber. It contains some fiber, but not as much as other options like bran muffins.

Cottage cheese is a good source of protein, but it is not known for its high fiber content. While it can be a part of a balanced diet, it may not have a significant impact on relieving constipation.

A. Ask the client if they would like to watch television. B. Use short, simple sentences when speaking with the client. C. Allow the client to have 1 hr of time alone in their room. D. Move the client to a table where other clients are playing cards.

Correct Answer is B

Explanation

By using short, simple sentences, the nurse can effectively communicate with the client who is exhibiting signs of agitation and anxiety. This communication style can help reduce stress and confusion for the client and promote understanding.

Asking the client if they would like to watch television: While providing options for activities can be beneficial, it is important to address the client's current state of agitation and anxiety before suggesting any specific activities.

Allowing the client to have 1 hour of time alone in their room: While some clients may prefer solitude, in this case, the client's pacing and hand-wringing indicate signs of distress and may require therapeutic interventions rather than isolation.

Moving the client to a table where other clients are playing cards: This option may not address the client's current state of anxiety and pacing. Placing the client in a social setting with other clients might increase their distress and agitation.

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

Nursing Test Bank

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