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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason: Murphy sign is a finding that indicates cholecystitis, which is inflammation of the gallbladder. It is elicited by palpating the right upper quadrant of the abdomen and asking the client to take a deep breath. The client will experience pain and stop breathing in if cholecystitis is present.

Choice B Reason: McBurney sign is a finding that indicates appendicitis, which is inflammation of the appendix. It is elicited by palpating the right lower quadrant of the abdomen at a point one-third of the distance from the anterior superior iliac spine to the umbilicus. The client will experience pain and tenderness if appendicitis is present.

Choice C Reason: Cullen's sign is a finding that indicates intra-abdominal bleeding, which can be caused by various conditions such as ruptured ectopic pregnancy, pancreatitis, or trauma. It is characterized by bruising around the umbilicus due to blood accumulation under the skin.

Choice D Reason: Homan sign is a finding that indicates deep vein thrombosis (DVT), which is a blood clot in a deep vein, usually in the leg. It is elicited by dorsiflexing the foot and squeezing the calf muscle. The client will experience pain and resistance if DVT is present.

A. If I feel nervous or have tremors, I should only take half the dose. B. I can expect diarrhea, insomnia, and excessive sweating. C. I need to call my healthcare provider if my heart rate becomes fast. D. I should take the medication in the evening.

Correct Answer is C

Explanation

Choice A Reason: If I feel nervous or have tremors, I should not only take half the dose, but I should contact my healthcare provider, as these may indicate signs of overdose or hyperthyroidism.

Choice B Reason: I cannot expect diarrhea, insomnia, and excessive sweating, but these are possible side effects of overdose or hyperthyroidism.

Choice C Reason: I need to call my healthcare provider if my heart rate becomes fast, as this may indicate a serious adverse reaction or overdose of levothyroxine sodium.

Choice D Reason: I should not take the medication in the evening, but in the morning on an empty stomach at least 30 minutes before breakfast, as this ensures better absorption and prevents insomnia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with data collection of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present?

Correct Answer is A

Explanation

A nurse reinforces instructions to a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions?

Correct Answer is C

Explanation

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