The nurse is caring for a male client who has a platelet count of 58,000/mm3 (58 x 109/L). What action by the nurse is most appropriate?

Limit visitors to healthy adults.

Institute neutropenic precautions.

Encourage high-protein foods.

Educate the client to use an electric razor when shaving.

Answer and Explanation

The Correct Answer is D

Thrombocytopenia is a condition where the platelet count falls below the normal range of 150,000 to 450,000/mm3. When levels drop significantly, the patient’s ability to achieve hemostasis is compromised, increasing the risk of spontaneous or prolonged bleeding. Nursing care focuses on bleeding precautions to minimize trauma and prevent internal or external hemorrhaging.

Rationale:

A. Limiting visitors is an intervention used for patients who are immunocompromised, not specifically for those with low platelets. Thrombocytopenia affects the clotting system rather than the immune system's ability to fight infection. While general hygiene is important, restricting visitors does not provide any protection against the primary risk of bleeding associated with this condition.

B. Neutropenic precautions are instituted when the absolute neutrophil count is dangerously low, usually below 1,000/mm3. This patient has a low platelet count, not necessarily a low white blood cell count. Applying these precautions would be clinically inappropriate as they focus on preventing infection rather than managing the risk of hemorrhage and vascular injury.

C. Encouraging high-protein foods is a general nutritional intervention that may help with tissue repair but does not address the acute risk of thrombocytopenia. Diet does not have a rapid or direct effect on increasing the platelet count in most clinical settings. The nurse's priority must be the immediate physical safety of the patient to prevent injury.

D. Educating the client to use an electric razor is the most appropriate action to prevent cutaneous trauma. A standard blade razor can cause small nicks and cuts that may bleed excessively due to the client’s low platelet count of 58,000/mm3. Bleeding precautions are essential to protect the patient from unnecessary blood loss and hematoma formation.

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Correct Answer is A

Explanation

Acute pancreatitisis an inflammatory condition characterized by the premature activation of digestive enzymes within the pancreas, leading to autodigestion. This process causes extensive tissue necrosis and hemorrhage, stimulating a massive inflammatory response. The resulting stimulation of visceral nociceptors in the retroperitoneum leads to intense, unrelenting pain that is often the primary reason patients seek emergency medical care.

Rationale:

A.Severe abdominal painis the hallmark and priority symptom of acute pancreatitis. This pain is typically described as "boring" and radiates to the back, caused by enzyme-mediated inflammation and peritoneal irritation. Managing this intense pain is a top priority because it causes significant physiological stress, including tachycardia and hypertension, and indicates the severity of the inflammatory process.

B.Nausea and vomiting are common symptoms of pancreatitis but are considered secondary to the inflammatory process and pain. While they contribute to fluid and electrolyte imbalances, they are not the "priority" problem that defines the clinical presentation. Pain management and fluid resuscitation are the primary therapeutic goals that take precedence over simple antiemetic therapy.

C.Jaundice and itching (pruritus) occur if the pancreatitis is caused by biliary obstruction (gallstones) or if the head of the pancreas compresses the common bile duct. However, these are not universal symptoms and are often delayed. They do not represent the acute, distressing priority that defines the initial presentation of pancreatic inflammation and autodigestion.

D.An elevated temperature is an expected part of the systemic inflammatory response in pancreatitis. However, fever is a clinical sign rather than a problem "reported" by the client as their primary concern. While the nurse monitors temperature to detect secondary infection or abscess, the client's most urgent and distressing report will always be the excruciating pain.

A. “Some medications have been known to cause hepatitis A." B. “I may have been exposed when we ate shrimp last weekend." C. “My infection with Epstein-Barr virus can co-infect me with hepatitis A." D. “I was infected with hepatitis A through a recent blood transfusion.”

Correct Answer is B

Explanation

Hepatitis Ais an acute, self-limiting viral infection of the liver caused by the Hepatitis A virus (HAV). It is primarily transmitted via the fecal-oral route, often through the consumption of contaminated water or undercooked shellfish. Unlike other forms of hepatitis, it does not result in chronic liver disease but causes significant hepatic inflammationand jaundice during the acute phase of the illness.

Rationale:

A.Medications can cause toxic or drug-induced hepatitis, but they do not cause Hepatitis A. Hepatitis A is strictly a viral infection caused by a specific pathogen, HAV. While certain drugs like acetaminophen can damage hepatocytes, they cannot spontaneously generate a viral infection, making this client statement scientifically inaccurate regarding the etiology of the disease.

B.Shellfish, such as shrimp or oysters, are common vectors for Hepatitis A if they are harvested from waters contaminated with human sewage. Because HAV is hardy and can survive in water, eating contaminated seafoodthat is raw or under-cooked is a classic route of transmission. This statement correctly identifies a likely source of exposure consistent with the fecal-oral transmission mechanism.

C.While Epstein-Barr virus (EBV) can cause liver inflammation (mononucleosis hepatitis), it is not a "co-infection" factor specific to the replication or transmission of Hepatitis A. Hepatitis A does not require a co-virus, unlike Hepatitis D which requires Hepatitis B. The client is confusing general viral infections with the specific pathophysiology of the HAV pathogen.

D.Hepatitis A is very rarely transmitted through blood transfusions because the viremic phase is brief and the virus is primarily shed in feces. Bloodborne transmission is more characteristic of Hepatitis B, C, and D. The client’s statement reflects a misunderstanding of the primary transmission precautionsnecessary for HAV, which focus on hand hygiene and food safety.

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The nurse is caring for a male client who has a platelet count of 58,000/mm3 (58 x 109/L). What action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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