Nokea
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about:
- A. Bleeding precautions
- B. Prevention of falls
- C. Oxygen therapy
- D. Conservation of energy
Correct Answer: A
Rationale: With a platelet count of 80,000, the client is at risk for bleeding, so teaching bleeding precautions is critical to prevent complications.
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A client with schizophrenia spends much of his time pacing the floor, rocking back and forth, and moving from one foot to another. The client's behaviors are an example of:
- A. Dystonia
- B. Tardive dyskinesia
- C. Akathisia
- D. Oculogyric crisis
Correct Answer: C
Rationale: Akathisia is characterized by restlessness and constant movement, often a side effect of antipsychotic medications, as described.
A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
- A. The client is at risk for opportunistic diseases.
- B. The client is no longer communicable.
- C. The client's viral load is extremely low so he is relatively free of circulating virus.
- D. The client's T-cell count is extremely low.
Correct Answer: C
Rationale: A viral load of 200 copies/ml is low, indicating effective treatment and minimal circulating virus.
A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
- A. administer nitrate or nifedipine
- B. check the client for fecal impaction
- C. check the client for bladder distention
- D. place the bed in high Fowler's position
Correct Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, often triggered by bladder distention in spinal cord injuries above T6. Checking and relieving bladder distention is the priority.
The nurse is caring for a client taking levothyroxine (Synthroid) for hypothyroidism. Which finding indicates a side effect of this medication?
- A. weight loss
- B. weight gain
- C. light sensitivity
- D. excessive sleepiness
Correct Answer: A
Rationale: Weight loss can indicate excessive levothyroxine dosing, as it increases metabolism, unlike the other options, which are not typical side effects.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes during percussion sessions
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion create a vibration that helps loosen mucus in cystic fibrosis without causing injury.