Nokea
A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating platelets. The nurse recognizes a knowledge deficit when the client makes which of the following statements?
- A. I need to stop flossing and throw away my hard toothbrush.'
- B. I am glad that my report turned out normal.'
- C. Now I know why I have all these bruises.'
- D. I shouldn't jump off that last step anymore.'
Correct Answer: B
Rationale: Normal stem cells and megakaryocytes with decreased circulating platelets suggest a peripheral destruction issue, such as ITP, not a bone marrow production problem. The client's statement that the report is 'normal' indicates a misunderstanding, as the low platelet count is abnormal and requires management. The other statements reflect appropriate awareness of bleeding risks.
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A nurse is caring for a client at home on hospice care for terminal renal cancer. People are calling the nurse to inquire about the client's condition. The nurse should tell the callers:
- A. Please call the oncologist.
- B. The client is in a coma now.
- C. Please call the client's sister.
- D. The client is not expected to live much longer.
Correct Answer: C
Rationale: Directing callers to the client's sister respects privacy and ensures consistent communication, aligning with the family's preferences in hospice care.
The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin (Rifamate) for treatment of tuberculosis?
- A. Take the medication with antacids.
- B. Double the dosage if a drug dose is missed.
- C. Increase intake of dairy products.
- D. Limit alcohol intake.
Correct Answer: D
Rationale: Limiting alcohol intake prevents hepatotoxicity, a risk with isoniazid and rifampin. Antacids may reduce absorption. Doubling doses is dangerous. Dairy intake is unrelated.
The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
- A. Decreased blood flow
- B. Increased blood flow
- C. Slow blood flow
- D. Thrombus formation
Correct Answer: A
Rationale: The hallmark of PVD is decreased blood flow due to arterial narrowing from atherosclerosis or other occlusive processes. This reduced flow causes ischemia, leading to claudication (pain during walking) that is relieved by rest. Increased or slow blood flow and thrombus formation are not the primary characteristics.
As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identified Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions?
- A. Instruct the client to increase the amount eaten at each meal.
- B. Encourage the client to eat smaller amounts more frequently.
- C. Explain that if vomiting occurs after a meal, nothing more should be eaten that day.
- D. Inform the client that bland foods are typically less nutritional and should be used minimally.
Correct Answer: B
Rationale: Smaller, frequent meals help prevent dumping syndrome and ensure adequate nutrition post-gastrectomy. Large meals, fasting after vomiting, or avoiding bland foods are not appropriate.
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should be necessary:
- A. Family history.
- B. Lifestyle choices.
- C. Age.
- D. Menopause or hormonal events.
Correct Answer: C
Rationale: Age is the most significant risk factor for cancer, as the incidence of most cancers increases with advancing age due to cumulative genetic and environmental damage.