When caring for a client diagnosed with thrombocytopenia, the nurse should plan to:
encourage vigorous tooth brushing with a soft bristle toothbrush.
avoid needle sticks or other invasive procedures as much as possible.
hold all stool softeners and laxatives until otherwise ordered.
obtain a low temperature every 8 hours.`
The Correct Answer is B
Choice A reason: The nurse should not encourage vigorous tooth brushing with a soft bristle toothbrush. Thrombocytopenia is a condition where the blood has a low number of platelets, which are cells that help with clotting. ¹ Vigorous tooth brushing can cause bleeding of the gums, which can be hard to stop in a client with thrombocytopenia. The nurse should advise the client to use a soft sponge or swab to clean the teeth and mouth gently.
Choice B reason: The nurse should avoid needle sticks or other invasive procedures as much as possible. Needle sticks and other invasive procedures can cause bleeding, bruising, or infection in a client with thrombocytopenia. ¹ The nurse should use the smallest gauge needle possible, apply pressure for at least 10 minutes after the procedure, and monitor the site for any signs of bleeding or infection. The nurse should also avoid unnecessary blood draws or injections, and use non-invasive methods whenever possible.
Choice C reason: The nurse should not hold all stool softeners and laxatives until otherwise ordered. Stool softeners and laxatives can help prevent constipation and straining, which can cause hemorrhoids or anal fissures in a client with thrombocytopenia. ¹ The nurse should encourage the client to take stool softeners and laxatives as prescribed, drink plenty of fluids, and eat high-fiber foods to promote regular bowel movements.
Choice D reason: The nurse should not obtain a low temperature every 8 hours. A low temperature is not a relevant or accurate measurement for a client with thrombocytopenia. The nurse should obtain a normal temperature, which is around 98.6°F (37°C), using a non-invasive method, such as an oral or tympanic thermometer. ² The nurse should avoid using a rectal thermometer, as it can cause bleeding or infection in a client with thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The pain you have is because your heart valves are damaged is not the most appropriate response. This statement may apply to a client with valvular heart disease, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that affects the blood vessels that supply the heart, not the heart valves.
Choice B reason: Your heart muscle is weak and is not pumping forcefully is not the most appropriate response. This statement may apply to a client with heart failure, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that reduces the blood flow to the heart, not the heart's contractility.
Choice C reason: The pain is caused by decreased oxygen to the heart muscle is the most appropriate response. This statement accurately describes the cause of angina, which is the chest pain that occurs when the heart does not receive enough oxygen due to narrowed or blocked coronary arteries. The nurse should also inform the client about the factors that can trigger or relieve angina, such as physical exertion, emotional stress, cold weather, or nitroglycerin.
Choice D reason: The layers of your heart are weak and thin is not the most appropriate response. This statement may apply to a client with cardiomyopathy, but not necessarily to a client with coronary artery disease. The nurse should explain that coronary artery disease is a condition that affects the blood vessels that supply the heart, not the heart's structure.
Correct Answer is B
Explanation
Choice A reason: Performing meditation every day will not be the most important information that the nurse should stress first. Meditation is a practice that involves focusing the mind on a particular object, thought, or activity, and can help reduce stress, anxiety, and blood pressure. However, meditation alone is not enough to prevent or treat coronary artery disease, which is a condition where the arteries that supply blood to the heart become narrowed or blocked by plaque. The nurse should advise the client to practice meditation as a complementary therapy, but not as the primary intervention.
Choice B reason: It is important to look into a smoking cessation program is the most important information that the nurse should stress first. Smoking is a major risk factor for coronary artery disease, as it damages the lining of the arteries, increases the buildup of plaque, reduces the oxygen in the blood, and raises the blood pressure and heart rate. Smoking can also worsen the symptoms and complications of coronary artery disease, such as chest pain, shortness of breath, or heart attack. The nurse should urge the client to quit smoking as soon as possible, and provide them with resources and support to help them achieve this goal.
Choice C reason: It is important to take a fish oil capsule daily is not the most important information that the nurse should stress first. Fish oil is a source of omega-3 fatty acids, which are beneficial for the heart and blood vessels, as they can lower the triglycerides, reduce inflammation, and prevent blood clots. However, fish oil alone is not enough to prevent or treat coronary artery disease, which is a condition where the arteries that supply blood to the heart become narrowed or blocked by plaque. The nurse should recommend the client to take fish oil as a supplement, but not as the main treatment.
Choice D reason: You will not be able to eat meat or have other fats in your diet is not the most important information that the nurse should stress first. A healthy diet is essential for preventing and managing coronary artery disease, as it can help lower the cholesterol, blood pressure, and weight, and improve the blood flow and oxygen to the heart. However, a healthy diet does not mean that the client has to avoid all meat or fats, as some of them can be beneficial for the heart, such as lean meat, poultry, fish, nuts, seeds, or olive oil. The nurse should educate the client to limit the intake of saturated and trans fats, which are found in red meat, butter, cheese, pastries, or fried foods, and to choose more fruits, vegetables, whole grains, and low-fat dairy products.
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