Nokea
The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations?
- A. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies.
- B. It is believed that the liver identifies the platelets as foreign bodies.
- C. It is now believed that the syndrome is related to an underactive immune system.
- D. The cause is unknown.
Correct Answer: A
Rationale: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune condition where antibodies coat platelets, marking them for destruction by the spleen. This leads to a low platelet count. The liver is not primarily involved, ITP is not due to an underactive immune system, and while 'idiopathic' means the exact trigger is unknown, the autoimmune mechanism is well-established.
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A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client?
- A. Request that the client remove all metal objects on the day of the scan.
- B. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test.
- C. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test.
- D. Tell the client that she should report any significant pain to her physician at least 2 days before the test.
Correct Answer: A
Rationale: Metal objects can interfere with the bone-density scan, so they must be removed. Calcium intake or pain reporting is not required for the test.
A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?
- A. Hypotension.
- B. Decreased serum potassium level.
- C. Rapid, deep respirations.
- D. Warm, dry skin.
Correct Answer: C
Rationale: Rapid, deep respirations (Kussmaul respirations) in diabetic ketoacidosis are a compensatory mechanism for acidosis, leading to significant fluid loss through hyperventilation.
Which intervention promotes comfort post-cystectomy?
- A. Encourage deep breathing.
- B. Restrict all fluids.
- C. Keep in supine position.
- D. Administer IV antibiotics.
Correct Answer: A
Rationale: Deep breathing prevents respiratory complications and promotes comfort.
A common abnormal laboratory result associated with the development of peripheral vascular disease (PVD) is:
- A. High serum calcium level
- B. High serum lipid levels
- C. Low serum lipid levels
- D. Low serum calcium level
Correct Answer: B
Rationale: High serum lipid levels, particularly elevated low-density lipoprotein (LDL) cholesterol, are a major risk factor for atherosclerosis, which underlies PVD. Lipid accumulation in arterial walls leads to plaque formation, narrowing vessels and reducing blood flow. Calcium levels are not directly associated with PVD, and low lipid levels are not a risk factor.
The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.