a nurse is planning care for a client with thrombocytopenia which action should the nurse include in the care plan a nurse is planning care for a client with thrombocytopenia which action should the nurse include in the care plan
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ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include in the care plan?

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased bleeding tendencies. Providing a stool softener helps prevent constipation and straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is important for oral hygiene but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to preventing infections in immunocompromised clients. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems but is not specifically targeted at managing thrombocytopenia.

2. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

3. For a patient on a ketogenic diet, which macronutrient is primarily increased?

Correct answer: C

Rationale: The correct answer is C: Fats. A ketogenic diet is characterized by high fat intake, moderate protein intake, and very low carbohydrate intake. This diet aims to shift the body's metabolism to use fat as the primary source of energy instead of carbohydrates. Increasing fat intake while reducing carbohydrates is essential for achieving and maintaining a state of ketosis. Therefore, choices A, B, and D are incorrect as they do not align with the macronutrient adjustments required for a ketogenic diet.

4. A client with systemic sclerosis has been in bed for 2 weeks due to fatigue and abdominal pain. Today, the client came into the clinic complaining of her leg being hot, red and painful. What does the nurse suspect?

Correct answer: Deep vein thrombosis

Rationale:

5. A nurse practitioner is assessing a 7-year-old boy who has been brought to the clinic by his mother, who is concerned about her son's increasingly frequent, severe headaches. Which of the nurse's questions is least likely to yield data that will confirm or rule out migraines as the cause of his problem?

Correct answer: C

Rationale: The correct answer is C. In assessing a child for migraines, asking about food allergies is least likely to yield data that will confirm or rule out migraines as the cause of his headaches. Food allergies are unrelated to the typical symptoms and triggers of migraines, such as family history, associated symptoms like nausea and vomiting, and pain-free intervals between headaches. Therefore, in this scenario, focusing on food allergies is less relevant for identifying migraines as the cause of the boy's headaches.

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