The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

Correct Answer: C

Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.

Correct Answer: D

Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.

Correct Answer: A

Rationale: The correct answer is A because exercising the bitten extremity can increase the spread of the venom. Choice B is correct as poisonous snake bites typically leave two fang marks. Choice C is correct as immediate severe pain and swelling are common symptoms of a poisonous snake bite. Choice D is incorrect as a tourniquet should not be used for snake bites as it can lead to complications such as tissue damage and increased risk of infection.

Correct Answer: A

Rationale: The correct answer is A because the drug should be resumed when the WBC count falls to 5,000mm3 to ensure the client's safety and efficacy of treatment. This criterion indicates that the client's immune system has recovered sufficiently to tolerate the drug. Choices B, C, and D are incorrect because they do not directly correlate with the client's immune system recovery, which is crucial for drug tolerance. Choice B focuses on the rise in WBC count, not the fall to a specific level. Choice C is related to a cosmetic side effect, not clinical readiness. Choice D is unrelated to immune system recovery.

Correct Answer: C

Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.

Correct Answer: B

Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly. A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful. C: Opening the mouth wide while talking is not necessary and may be seen as patronizing. D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.

Correct Answer: D

Rationale: The correct answer is D: A bleeding disorder. Thoracentesis involves inserting a needle into the pleural space to remove fluid. A bleeding disorder increases the risk of excessive bleeding during the procedure. This can lead to complications such as hematoma formation, pneumothorax, or even life-threatening bleeding. It is crucial to assess and address bleeding disorders before performing thoracentesis to ensure the safety of the client. A: A seizure disorder is not a contraindication for thoracentesis unless uncontrolled seizures could compromise the safety of the procedure. B: Anemia alone is not a contraindication for thoracentesis, as it does not directly increase the risk of complications during the procedure. C: Chronic obstructive pulmonary disease is not a contraindication for thoracentesis unless it is severe and compromises the client's ability to tolerate the procedure.

Correct Answer: D

Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support. A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls. B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls. C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies. In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.

Correct Answer: B

Rationale: The correct answer is B: Blurring of vision. This is typically the first symptom of a cataract because the clouding of the lens causes light to scatter, leading to blurred vision. Dry eyes (A) and eye pain (C) are not typically associated with cataracts. Loss of peripheral vision (D) is more commonly seen in conditions like glaucoma. In summary, blurring of vision is the hallmark symptom of cataracts due to lens clouding, distinguishing it from other eye conditions.