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Questions 158

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Question 1 of 5

A patient with thrombocytopenia has a platelet count of 80,000. It will be most important to teach the client about:

Correct Answer: A

Rationale: Thrombocytopenia (low platelet count) increases bleeding risk. Teaching measures to reduce bleeding (e.g. avoiding trauma using soft toothbrushes) is critical. Fluid intake oxygenation and energy conservation are less directly related to the condition.

Question 2 of 5

A 32-year-old female client is being treated for Guillain-Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Correct Answer: C

Rationale: Headaches are not associated with Guillain-Barré syndrome. Loss of superficial and deep tendon reflexes is expected with this diagnosis. Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. Facial paralysis is expected and is not considered abnormal.

Question 3 of 5

A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:

Correct Answer: C

Rationale: Immobilizing the arm with a splint is critical to prevent further damage to the injured area, reduce pain, and promote healing. Asking about allergies should have been done prior to administering antibiotics, checking immunization records is not a priority in this acute situation, and pain medication, while important, is secondary to stabilizing the injury.

Question 4 of 5

A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:

Correct Answer: C

Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.

Question 5 of 5

A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:

Correct Answer: A

Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.

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