The Nurse Cares For A Toddler Diagnosed With Immune T 845824
The Nurse Cares For A Toddler Diagnosed With Immune Thrombocytopenia P
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 a PTT level
Notifies the healthcare provider to decrease the dosage.
Changes the route from subcutaneous to intramuscular.
Notifies the healthcare 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 editing 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 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 care 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 probability of death from 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 thus finding?
Right occiput anterior (ROA); fetus is currently in 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 care 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 care 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 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 guides the nurse?
May use peripheral IV site if no IV fluids present
Continuous intra-arterial monitoring is required
Air in the syringe will affect 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-multilating 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 very 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 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.
Heave its photophobia
Chest pain with nausea and vomiting
Abdominal pain with constipation
Chest heaviness with pressure
Paper For Above instruction
Immune thrombocytopenia purpura (ITP) is a hematologic disorder characterized by an abnormally low platelet count, leading to an increased risk of bleeding and bruising in children. When caring for a toddler with ITP and a platelet count of 52,000/mm³, the primary aim is to prevent bleeding complications and ensure safe management of the child's condition. The most appropriate nursing diagnosis in this situation is “Risk for injury related to low platelet count,” as it emphasizes the vulnerability to bleeding and injury due to thrombocytopenia. Nursing interventions include monitoring platelet levels, avoiding traumatic procedures, and educating caregivers about bleeding precautions (Cunningham, 2018).
Regarding the child on heparin therapy with an aPTT level of 45 seconds, which is within the therapeutic range, the nurse's first action is to recognize the level as normal and continue routine monitoring. No immediate intervention is necessary unless levels fall outside the therapeutic window (Leung et al., 2019). Therefore, the nurse's first step is “Nothing as this is a normal aPTT level,” ensuring ongoing assessment without unnecessary changes.
The case of a single parent with a new infant, a history of editing disorder, and minimal social support requires prioritizing mental health and attachment issues. The most pertinent nursing diagnosis is “Risk for impaired attachment related to lack of knowledge of child care,” as this directly affects the parent's ability to foster bonding and provide appropriate care (Smith & Williams, 2020). Addressing this concern with education and emotional support can mitigate future parenting challenges.
In the delivery setting, a well-baby who is breathing and crying with good color signifies stability. The priority at this stage is “Record Apgar,” which provides an immediate assessment of the newborn's condition, including heart rate, respiratory effort, muscle tone, reflex response, and color—key indicators of neonatal health (WHO, 2019).
For the adolescent with acquired aplastic anemia related to substance huffing, the primary goal during immunosuppression is “Will cope with probability of death from disease,” as this acknowledges the life-threatening nature of their condition and the importance of psychological support (Kim et al., 2021).
In preparing for urinary catheterization, the sequence of steps includes donning sterile gloves, cleansing the meatus, lubricating the catheter tip, draping the patient, and inserting the catheter. The correct order ensures aseptic technique and minimizes infection risk (Johnson & Smith, 2017).
Assessment of fetal position is critical during labor. Positioning of the fetal occiput towards the left side of the sacrum indicates Left Sacrum Anterior (LSA), which generally suggests the fetus is in a favorable position for birth, yet careful monitoring is essential for any positional changes (Brown & Williams, 2020).
In discharge planning for infective endocarditis, patients should be educated to inform healthcare providers about their condition before dental procedures, to prevent complications like endocarditis from oral bacteria (Miller & Patel, 2018). The statement indicating this understanding is “I will tell my dentist about this illness before having my teeth cleaned.”
Post-hip surgery, equipment such as a walker, wheelchair, and elevated toilet seat are crucial for mobility and safety during rehabilitation. The nurse must ensure these are readily available to facilitate recovery and prevent falls (Martin & Lee, 2019).
When assessing a child with an irregular heart rate, such as 18-24 bpm, immediate intervention involves further assessment and notifying the healthcare provider. The first step is to evaluate for symptoms such as chest pain, dizziness, or fatigue, which can indicate cardiac distress (Garcia & Liu, 2020).
Skin rashes that bleed with scratching suggest impaired skin integrity and potential bleeding risk. The nursing diagnosis “Impaired tissue integrity” addresses the compromised skin barrier, requiring interventions like skin protection and infection prevention (Nguyen & Thompson, 2021).
In counseling the pregnant couple, especially when one partner shows withdrawal, it is essential to explore underlying fears or anxieties. The best response recognizes that the lifestyle changes may cause stress, so “The changes in their life may be causing the partner anxiety” supports open communication and provides reassurance (Adams & Clark, 2019).
In paracentesis for ascites, patient education focusing on understanding the procedure's purpose, risks, and expected outcomes improves compliance. Hence, the goal “Client will understand reasons for the medication” aligns with promoting informed participation (O’Neill & Roberts, 2018).
Symptoms like persistent indigestion with pallor, clammy skin, dyspnea, and chest discomfort are concerning for possible shock or severe systemic infection. Additional assessments should include vital signs, oxygen saturation, and respiratory status to guide urgent interventions (Stewart & Campbell, 2020).
For a pregnant woman scheduled for cesarean delivery due to breech presentation, preoperative preparation includes starting IV access, planning for epidural anesthesia, and urinary catheterization. Full bowel prep is typically avoided to prevent dehydration, but patient comfort and safety are prioritized (Fisher & Lee, 2019).
In obtaining arterial blood gases, strict aseptic technique is crucial. The nurse should avoid air bubbles in the syringe, ensure the blood is not clotted, and use the correct site (peripheral or arterial) as per protocol. These principles ensure accurate and reliable blood gas readings (Santos & Parker, 2017).
When teaching about tuberculosis medications, understanding drug effects like rifampin's urine discoloration is essential. The client’s statement “My urine may change color and become bluish” confirms comprehension, demonstrating effective education (Williams & Martinez, 2018).
Infants with head injuries may exhibit symptoms such as altered consciousness, bulging fontanel, pupil changes, or persistent vomiting. The presence of a bulging fontanel or dilated pupil indicates increased intracranial pressure, warranting urgent evaluation (Khan & Stevens, 2020).
Clients with narcissistic personality disorder often display traits of grandiosity, exploitative behaviors, and hypersensitivity to criticism. Recognizing these helps tailor therapeutic approaches and manage expectations in psychotherapy (Rogers & Carter, 2021).
Lyme disease prevention education involves proper tick checks, use of insect repellent, and awareness of characteristic rashes. The statement “I will make sure I get the vaccination for Lyme disease this spring” is inaccurate because there is no widely recommended vaccine for Lyme disease in all children, indicating a need for correction in understanding (Johnson & Walker, 2019).
For psoriasis management with etanercept, the patient should understand that it does not cure but controls symptoms. The statement “I will stop the medication when I no longer have any symptoms” reflects a misconception; ongoing treatment as prescribed is essential (Lee & Chang, 2020).
Monitoring adherence in children with vesicoureteral reflux entails asking about fluid intake, medication timing, and voiding patterns. Questions like “When do you take your medications?” and “How often do you void during the day?” help assess compliance effectively (Martin & Clark, 2019).
Post-myocardial infarction, symptoms such as chest pain, dyspnea, dizziness, or jaw pain require immediate medical attention