A nurse is monitoring a client who is receiving chemotherapy and has a platelet count of 20,000 mm3. Which of the following findings should the nurse identify as the priority?
Fatigue
Anorexia
Bleeding
Fever
The Correct Answer is C
Choice A Reason: Fatigue is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as anemia, infection, or depression.
Choice B Reason: Anorexia is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as nausea, pain, or anxiety.
Choice C Reason: Bleeding is the priority finding for a client who has a low platelet count, as it indicates that the client is at risk of hemorrhage and shock due to impaired blood clotting.
Choice D Reason: Fever is not the priority finding for a client who has a low platelet count, but it may indicate an infection that requires prompt treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: Heat intolerance is a common finding in hyperthyroidism, as the increased metabolic rate causes the body to produce more heat and sweat.
Choice B Reason: Diarrhea is a common finding in hyperthyroidism, as the increased motility of the gastrointestinal tract causes more frequent and loose stools.
Choice C Reason: Weight loss is a common finding in hyperthyroidism, as the increased metabolism and appetite cause the body to burn more calories than it consumes.
Choice D Reason: Weight gain is not a common finding in hyperthyroidism, but it may indicate other conditions such as hypothyroidism or Cushing's syndrome.
Choice E Reason: Bradycardia is not a common finding in hyperthyroidism, but it may indicate other conditions such as heart block or beta-blocker use.
Correct Answer is B
Explanation
Choice A Reason: Swollen, painful joints are not a sign of Lyme disease in the early stage, but they may occur in the late stage, which can take months or years to develop.
Choice B Reason: An expanding circular rash, also known as erythema migrans, is a sign of Lyme disease in the early stage, which usually appears within 3 to 30 days after the tick bite. The rash may have a bull's-eye appearance and can spread up to 12 inches in diameter.
Choice C Reason: Decreased level of consciousness is not a sign of Lyme disease, but it may indicate other serious conditions such as meningitis, encephalitis, or stroke.
Choice D Reason: Necrosis at the site of the bite is not a sign of Lyme disease, but it may indicate a brown recluse spider bite, which can cause tissue damage and ulceration.
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