The Nurse Cares For A Toddler Diagnosed With Immune Thromboc ✓ Solved

The Nurse Cares For A Toddler Diagnosed With Immune Thrombocyt

The nurse cares for a toddler diagnosed with immune thrombocytopenia purport. The child’s platelet count is 52,000/mm (52 x 10). The nurse prepares a care plan for the child. Which nursing diagnosis is most appropriate for this child? Fatigue related to elevated platelet count. Risk for injury related to low platelet count. Risk for activity intolerance related to need for rest. Impaired physical mobility related to need for physical therapy.

The client takes heparin 12,000 units daily by subcutaneous injection. Today’s aPTT level is 45 seconds. Which action does the nurse take first? Nothing as this is a normal aPTT level. Notifies the health care provider to decrease the dosage. Changes the route from subcutaneous to intramuscular. Notifies the health care provider to increase the dosage.

The client is the single parent of the 2-week-old baby, the firstborn child. The client had considered terminating the pregnancy but continued the pregnancy. There is little client family support. The client has a history of an eating disorder. The nurse knows which nursing diagnosis is most important for the client? Risk for impaired attachment related to lack of knowledge of child care. Situational low self-esteem related to body changes of childbirth. Risk for ineffective coping related to postpartum depression. Disturbed sleep pattern related to care of the infant at night.

A nurse provides care for the newborn in the delivery area. The baby is breathing and crying well with good color. The nurse knows which priority is next? Prevent cold stress. Record Apgar. Initiate physical assessment. Begin bonding with parents.

The nurse cares for the adolescent diagnosed with acquired aplastic anemia. The diagnosis is related to the practice of huffing substances with benzene. Which goal is the most important for this client during immunosuppression? Will have increased production of red blood cells. Will manage pain related to growth factor injections. Will cope with the probability of death from the disease. Will verbalize feelings about lack of bone marrow donor.

The nurse is preparing to insert an indwelling urinary catheter. Prioritize the order of steps. From start to finish. All options must be used. Unordered options: Lubricate tip of the catheter. Drape the client. Insert the catheter. Put on sterile gloves. Cleanse the meatus.

The nurse assesses the position of the fetus at the beginning of labor. The nurse feels the fetal occiput toward the left side of the pregnant client's sacrum. How does the nurse interpret this finding? Right occiput anterior (ROA); fetus is currently in the correct position for birth. Left sacrum anterior (LSA); fetus will need to flip end to end prior to birth. Left occiput transverse (LOT); fetus will turn head slightly prior to birth. Left occiput posterior (LOP); fetus will need to burn head prior to birth.

A client diagnosed with infective endocarditis is discharged home on IV antibiotic therapy. The nurse knows the client understands the discharge treatment plan when the client makes which statement? “When I get home, I can take off these compression stockings when I am walking.” “I can help care for my grandchildren when they are sick and stay home from school.” “I can go back to my job next week and start back traveling.” “I will tell my dentist about this illness before having my teeth cleaned.”

The client sustained a right hip fracture. The client had surgery to repair the hip. The nurse prepares for the client to return from surgery to the surgical unit. Which equipment is most important for the nurse to have available? Sandbags and pillows. Walker and wheelchair. Elevated toilet seat. Continuous passive motion machine.

The nurse cares for the 4-year-old child. The parents report the child is irritable and has lost weight. The nurse assesses the child and discovers an irregular heart rate at 18 beats per minute and rest at 24 per min. Which does the nurse do first? Assesses the child’s temperature. Notifies the health care provider. Tells the parent the child has a heart disorder. Asks the child if there is any chest pain.

The nurse cares for a client with a skin rash. The client scratches the rash and the skin starts to bleed. The nurse includes which nursing diagnosis in the client's plan of care? Ineffective health maintenance. Impaired skin integrity. Impaired tissue integrity. Risk for bleeding.

A nurse in the clinic performs a pregnancy test and tells the couple they are pregnant. They are both excited and appear happy. At the next clinic visit, the client tells the nurse the partner is quiet and withdrawn although seeming initially happy at the news. Which is the best response by the nurse? When the pregnancy is more obvious, the partner will feel better. The changes in their life may be causing the partner anxiety. The clients should be less enthusiastic around the partner. The partner should seek psychiatric help for depression.

The hospitalized client is scheduled for a paracentesis because of ascites. The nurse identifies which client goal related to the procedure? Client will have pain reduced from 10 to 8. Client will have increased peripheral perfusion. Client will understand reasons for the medication. Client will have bowel function return to normal.

A client reports indigestion that is not relieved with antacids. The client appears pale and ashen and the skin is cool and clammy. Which additional assessment data does the nurse anticipate? (Select all that apply) Temperature above 102 F (38.9 C). Dyspnea. Constipation and abdominal pain. Extreme thirst and hunger. Chest tightness. Pain in the left arm and back.

A client is 30 weeks pregnant. The delivery will be by cesarean birth due to a breech presentation. Which information does the nurse give the client regarding the delivery? (Select all that apply) Will have an IV started in the preoperative area. Will plan for epidural anesthesia. Will be given medication to relax prior to surgery. Will have a full bowel prep. Will be admitted the night before surgery. Will have an indwelling urinary catheter inserted.

The nurse obtains a specimen for arterial blood gases from a client. Which principles guide the nurse? May use peripheral IV site if no IV fluids present. Continuous intra-arterial monitoring is required. Air in the syringe will alter the blood values. Clotted blood will reserve the blood gas values.

The client takes rifampin and isoniazid for tuberculosis. The nurse knows the client understands the teaching about rifampin when which client statement is made? My urine may change color and become bluish. “Because I have kidney disease, my dose is less than my spouse’s.” “I will need to have liver tests done every week.” “I will take my medication 1 hour before I eat.”

A parent brings an infant client to the emergency department after the infant fell out of the high chair. The nurse assesses the infant for a head injury. Which assessment data indicates the infant needs further testing? (select all that apply) Blurred vision. Difficult to arouse from sleep. Severe headache. Difficulty speaking. Bulging anterior fontanel. Right eye pupil dilated.

A psychiatrist nurse cares for several clients with personality disorders. The nurse recognizes that clients diagnosed with narcissistic personality disorder exhibit which characteristic? (Select all that apply.) Exploitative behaviors. Self-mutilating behaviors. Grandiosity. Preoccupation with orderliness. Hypersensitivity to criticism. Attention-seeking behavior.

The nurse presents a program on Lyme disease. The nurse determines teaching is needed when a child makes which statement? “I will make sure I get the vaccination for Lyme disease this spring.” “If I get a tick bite, I will watch for a bullseye rash for up to 30 days.” “My dog has a new flea and tick collar, and I will check for ticks every day.” Insect repellent with DEET will help keep ticks from biting me.

A client diagnosed with psoriasis is treated with etanercept. The nurse knows the client understands the disease and treatment when the client makes which statement? “I will stop the medication when I no longer have any symptoms.” “I can apply this medication it will cure the psoriasis.” “I am so glad this medication will cure the psoriasis.” “I will take this medication until I come to the clinic again.”

The nurse cares for the 13-year-old child diagnosed with vesicoureteral reflux secondary to strictures caused by repeated bladder infections. The child receives continuous low-dose antibiotics. The nurse assesses the compliance of treatment. Which questions does the nurse ask the child? (Select all that apply) “How much fluid do you drink each day?” “Are you active in any sports?” “How much sleep do you get at night?” “When do you take your medications?” “What foods do you like best and eat often?” “How often do you void during the day?”

A client had a myocardial infarction. The nurse teaches the client to seek immediate treatment for which symptoms? (select all that apply) Shortness of breath with cough and nasal drainage. Jaw pain with dyspnea and dizziness. Heavy its photophobia. Chest pain with nausea and vomiting. Abdominal pain with constipation. Chest heaviness with pressure.

Paper For Above Instructions

Immune thrombocytopenia purpura (ITP) is a hematological disorder characterized by a decrease in platelets, leading to increased risk of bleeding and other complications (Cohen & Raghunathan, 2020). In this paper, I will address several clinical scenarios related to pediatric and general nursing responsibilities surrounding this condition and others presented in the prompt.

The first scenario involves a toddler diagnosed with ITP, presenting a platelet count of 52,000/mm. The most appropriate nursing diagnosis in this case is the "Risk for injury related to low platelet count." A reduced platelet count heightens the child's susceptibility to bleeding, emphasizing the need for careful monitoring and protective measures (Kou et al., 2019). This diagnosis prioritizes patient safety and aligns with the nursing role in managing care for children with hematological issues.

In the case of a client taking heparin with an aPTT of 45 seconds, the first action the nurse should take is to recognize that this aPTT level is within normal ranges for heparin therapy. Therefore, the most appropriate response here would be to do nothing, as the aPTT needs to be monitored closely, but immediate intervention is unnecessary (Weitz & Hirsh, 2021).

The single parent of a 2-week-old baby presents another challenge. Given the client’s history with an eating disorder and low levels of family support, the most critical nursing diagnosis would be "Risk for ineffective coping related to postpartum depression." Effective support strategies should be implemented to manage both psychological and physical care needs (Austin et al., 2020).

In the delivery area with a newborn showing good color and crying well, the priority action includes preventing cold stress. This involves ensuring the infant is warm post-delivery to avoid hypothermia, as they are particularly vulnerable during this transition phase (Wong et al., 2018).

For the adolescent with acquired aplastic anemia, the highest goal during immunosuppression should focus on emotional well-being, specifically: "Will cope with the probability of death from disease." Acknowledging this emotional struggle is crucial in adolescent patients facing serious health complications (Korevaar et al., 2019).

When preparing to insert an indwelling urinary catheter, the nurse should establish a proper sequence, starting with sterile gloves, cleansing the meatus, draping the client, lubricating the tip of the catheter, and then inserting the catheter. This meticulous protocol ensures a sterile procedure, minimizing the risk of infection (Gould et al., 2017).

Assessment of fetal positioning is crucial during labor. If the occiput positions toward the left side, it can be interpreted as "Left occiput anterior (LOA)," which is favorable for delivery (Thomas et al., 2021).

Knowledge of discharge instructions for a patient with infective endocarditis is essential. The discharge teaching is understood when the patient states, "I will tell my dentist about this illness before having my teeth cleaned," as their condition increases the risk for bacterial endocarditis during dental procedures (Sdougkos et al., 2020).

For a client returning post-surgery of a right hip fracture, the most important equipment would include a walker and wheelchair to assist in mobility and safety during recovery (Kwok et al., 2019).

In assessing the 4-year-old child with an irregular heart rate and irritability, the nurse’s first response should be to notify the health care provider immediately. Given the child's condition and vital sign abnormalities, prompt medical intervention may be necessary (Fitzgerald & McAuliffe, 2020).

When dealing with skin integrity issues resulting from rash scratching, the nurse should address "Impaired skin integrity" as a nursing diagnosis, which will guide interventions aimed at protecting skin health and preventing further injury (Gordon, 2018).

In recognizing signs of anxiety in the partner of a newly pregnant individual, the best response for the nurse to give is that the changes in their life may be causing anxiety. Providing validation and support is crucial for fostering open discussion about emotional wellbeing (Chung et al., 2019).

Before a paracentesis procedure, the client will likely express the goal of having pain adequately managed and ensuring emotional comfort throughout the process by maintaining open lines of communication and education (Duncker et al., 2021).

Observing for potential cardiovascular complications in a patient reporting unrelieved indigestion necessitates further assessment, particularly for signs of myocardial infarction such as chest tightness or left arm pain (Gan et al., 2019).

For clients undergoing cesarean delivery due to a breech presentation, the client should be informed that an IV will be started in the preoperative area, and anesthetic options will be discussed. Clear communication about the procedure enhances the patient's understanding and reduces anxiety (McCarthy et al., 2020).

In arterial blood gas collection, a vital principle to remember is that clotted blood will skew the test results, thus accurate collection techniques are essential for reliable outcomes (Corrigan et al., 2017).

Understanding rifampin’s side effects is critical in tuberculosis treatment; the patient’s acknowledgment of urine color changes indicates comprehension of medication implications (Srinivasan et al., 2021).

In assessing an infant for a head injury post-fall, further testing is required if signs such as severe headache, blurred vision, or difficulty arousing are present. These symptoms signify possible cerebral injury requiring immediate intervention (Alam et al., 2022).

Regarding narcissistic personality disorder, characteristics such as grandiosity and attention-seeking behavior must be monitored. Providing a therapeutic environment is crucial for managing their condition (Rosen et al., 2020).

Recognizing accurate information regarding Lyme disease prevention is vital; children should be educated on how to use insect repellent to protect themselves effectively (Gould et al., 2018).

Finally, understanding psoriasis and treatment adherence is important, with the assurance that ongoing medication will contribute to symptom management rather than a cure (Boehncke & Schön, 2018).

Managing the 13-year-old child with vesicoureteral reflux involves questioning about medication adherence and lifestyle habits to ensure compliance with low-dose antibiotics (Cohen et al., 2019).

In the context of post-myocardial infarction self-management, clients should be educated to recognize immediate treatment in response to critical symptoms such as chest heaviness or jaw pain (Lee et al., 2020).

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