A 55-year-old male patient is admitted to the hospital with a diagnosis of thrombocytopenia. Upon assessment, you note petechiae on his lower extremities, and he reports fatigue and occasional nosebleeds. Which of the following interventions should be prioritized for this patient?
Monitor platelet counts and assess for signs of bleeding.
Administer aspirin to manage pain and prevent clot formation.
Administer a diuretic to reduce fluid retention and swelling.
Encourage the patient to increase physical activity to improve circulation.
The Correct Answer is A
Choice A Reason:
Monitoring platelet counts and assessing for signs of bleeding is crucial for managing thrombocytopenia. Thrombocytopenia is characterized by a low platelet count, which increases the risk of bleeding. Regular monitoring helps in detecting any significant drops in platelet levels, allowing for timely interventions to prevent severe bleeding. Assessing for signs of bleeding, such as petechiae, bruising, or nosebleeds, is essential to manage the condition effectively and prevent complications.
Choice B Reason:
Administering aspirin to manage pain and prevent clot formation is not appropriate for patients with thrombocytopenia. Aspirin is an antiplatelet agent that inhibits platelet function, which can exacerbate bleeding tendencies in patients with low platelet counts. Using aspirin in this context could increase the risk of bleeding and is therefore contraindicated.
Choice C Reason:
Administering a diuretic to reduce fluid retention and swelling is not relevant for managing thrombocytopenia. Diuretics are used to manage conditions like hypertension and edema but do not address the underlying issue of low platelet counts. In fact, diuretics can lead to electrolyte imbalances, which may complicate the patient’s condition further.
Choice D Reason:
Encouraging the patient to increase physical activity to improve circulation is not a priority intervention for thrombocytopenia. While physical activity is generally beneficial for overall health, it can increase the risk of trauma and bleeding in patients with low platelet counts. It is important to avoid activities that could lead to injury and bleeding in these patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Increased appetite is not typically associated with anemia. Anemia generally leads to symptoms related to decreased oxygen-carrying capacity of the blood, such as fatigue, weakness, and shortness of breath. Increased appetite is more commonly linked to other conditions, such as hyperthyroidism or certain metabolic disorders.
Choice B Reason:
Fatigue is a common and significant symptom of anemia. When hemoglobin levels are low, the body’s tissues do not receive adequate oxygen, leading to feelings of tiredness and exhaustion. This is because hemoglobin is responsible for transporting oxygen from the lungs to the rest of the body. In anemia, the reduced oxygen delivery results in decreased energy levels and persistent fatigue.
Choice C Reason:
Weight gain is not typically associated with anemia. In fact, some forms of anemia, such as those caused by chronic diseases or malnutrition, may lead to weight loss rather than gain. Weight gain can be associated with other health issues, such as hypothyroidism or fluid retention, but not directly with anemia.
Choice D Reason:
Hypertension is not a common manifestation of anemia. Anemia usually leads to symptoms like pallor, shortness of breath, and fatigue due to the reduced oxygen-carrying capacity of the blood. Hypertension, or high blood pressure, is more commonly associated with cardiovascular diseases, kidney disorders, or endocrine conditions.
Correct Answer is B
Explanation
Choice A Reason:
Adrenal hyperplasia involves the enlargement of the adrenal glands, which can lead to an overproduction of adrenal hormones. However, it does not directly cause hyperpituitarism. Hyperpituitarism is related to the overactivity of the pituitary gland, not the adrenal glands.
Choice B Reason:
Pituitary adenoma is the most common cause of hyperpituitarism. These benign tumors in the pituitary gland lead to the overproduction of one or more pituitary hormones, causing symptoms such as severe headaches, visual disturbances, and joint pain. The pituitary gland’s overactivity due to the adenoma results in the excessive release of hormones, which can affect various bodily functions.
Choice C Reason:
Thyroid carcinoma is a type of cancer that affects the thyroid gland While it can cause hormonal imbalances, it does not typically lead to hyperpituitarism. The symptoms described are more consistent with a pituitary-related issue rather than a thyroid condition.
Choice D Reason:
Hypothalamic dysfunction can affect the pituitary gland’s function since the hypothalamus regulates pituitary hormone release. However, it is less likely to be the primary cause of hyperpituitarism compared to a pituitary adenoma. The direct overproduction of hormones by the pituitary gland is more commonly due to an adenoma.
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