The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?

Reasoning:

Choice A reason: Arranging for friends and family to sit with the client may provide comfort but does not directly prevent injury from agitation. Family presence cannot ensure physical safety during sudden movements, whereas padding side rails directly reduces harm from agitation-related impacts in head injury.

Choice B reason: Restraining the client increases agitation and injury risk in head-injured patients, as it can exacerbate distress and cause pressure injuries. Non-restrictive measures like padding are safer, reducing harm from agitation without compromising autonomy or worsening neurological status in this high-risk population.

Choice C reason: Padding side rails is the best intervention to prevent injury in an agitated client with a head injury. Agitation increases the risk of hitting bed rails, causing bruises or fractures. Padding absorbs impact, ensuring safety without restricting movement, addressing the immediate physical risk effectively.

Choice D reason: Administering opioids PRN may reduce pain but not agitation in head injury. Opioids can depress respiration and consciousness, potentially masking neurological changes or worsening ICP, making them less safe than padding side rails to prevent physical injury from agitation-related movements.

Reasoning:

Choice A reason: Teaching coughing and deep breathing techniques prevents respiratory infections but is not the primary intervention for immune thrombocytopenia (ITP). ITP involves autoimmune platelet destruction, increasing bleeding risk. While infection prevention is important, maintaining platelet counts through transfusion is more critical to prevent hemorrhage in ITP.

Choice B reason: Giving aspirin to control temperature is contraindicated in ITP, as aspirin inhibits platelet function, worsening bleeding risk in clients with low platelet counts. Fever management should use alternative antipyretics like acetaminophen, making aspirin administration inappropriate and potentially harmful in this condition.

Choice C reason: Administering platelets, as ordered, is a key intervention in immune thrombocytopenia when bleeding risk is high. ITP causes autoimmune destruction of platelets, leading to thrombocytopenia. Platelet transfusions restore counts, reducing the risk of spontaneous bleeding, such as intracranial or gastrointestinal hemorrhage, a critical concern in severe cases.

Choice D reason: Administering stool softeners prevents straining, which could cause bleeding in ITP due to low platelets. While useful, it is secondary to platelet transfusion, which directly addresses the primary issue of thrombocytopenia and bleeding risk, making it less urgent than restoring platelet counts.