A client has been diagnosed with thrombocytopenia. What are the primary nursing interventions while instituting corticosteroid therapy in this client?

Palpate the lymph nodes and tonsils every shift

Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)

Gradually taper the dose and frequency of medication

Examine the extremities for redness

Answer and Explanation

The Correct Answer is B

Reasoning:

Choice A reason: Palpating lymph nodes and tonsils is relevant for assessing infections or malignancies but is not a primary intervention for thrombocytopenia. Corticosteroids treat thrombocytopenia by suppressing autoimmune platelet destruction, and the focus is on bleeding prevention, not lymphoid assessment, which is secondary to managing low platelet counts.

Choice B reason: Eliminating aspirin and NSAIDs is critical in thrombocytopenia, as these drugs inhibit platelet function, increasing bleeding risk in patients with low platelet counts. Corticosteroids improve platelet production, but concurrent use of antiplatelet drugs could exacerbate bleeding tendencies, making their elimination a primary nursing intervention.

Choice C reason: Gradually tapering corticosteroids is important to prevent adrenal suppression but is not the primary intervention during initial therapy for thrombocytopenia. The immediate focus is on preventing bleeding complications due to low platelets, with tapering being a later consideration once platelet counts stabilize.

Choice D reason: Examining extremities for redness may detect infection or inflammation but is not the primary intervention for thrombocytopenia. Bleeding risk from low platelets is the main concern, and while redness could indicate complications, eliminating drugs that impair platelet function is more critical to prevent hemorrhage.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Acknowledging the client’s relief does not educate them about the TIA’s significance. TIAs indicate transient cerebral ischemia, increasing stroke risk, but this response fails to address the need for risk modification, missing an opportunity to promote preventive measures critical for stroke prevention.

Choice B reason: Stating that TIA symptoms resolve within 24 hours is factually correct but does not emphasize the serious nature of TIAs as stroke precursors. Without addressing risk reduction, this response fails to educate the client on the need for lifestyle changes or medical intervention to prevent future events.

Choice C reason: Saying all TIA patients will develop a stroke is inaccurate, as not all progress to stroke. TIAs significantly increase stroke risk, but many can be prevented with proper management. This response is overly fatalistic and does not encourage proactive risk reduction strategies.

Choice D reason: Explaining that a TIA is a warning sign and discussing risk reduction educates the client about its significance as a transient cerebral ischemia event, increasing stroke risk. This response promotes lifestyle changes, medication adherence, and medical follow-up, empowering the client to prevent future strokes effectively.

A. Administer aspirin daily as ordered B. Place a pressure-reducing mattress on the client’s bed C. Administer meperidine (Demerol) intramuscularly as needed for pain D. Provide mouth care every 4 hours with lemon-glycerin swabs

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Administering aspirin is contraindicated in DIC, as it inhibits platelet function, worsening bleeding risk in a condition already characterized by thrombocytopenia and coagulopathy. Aspirin’s antiplatelet effect could exacerbate hemorrhage, making it an inappropriate intervention for a client with active DIC-related bleeding tendencies.

Choice B reason: Placing a pressure-reducing mattress is appropriate in DIC to prevent skin breakdown, as clients are at risk for bleeding and bruising due to low platelets and coagulopathy. Immobility from critical illness increases pressure injury risk, and a specialized mattress minimizes tissue damage and supports skin integrity.

Choice C reason: Administering meperidine intramuscularly is inappropriate in DIC, as intramuscular injections can cause hematomas due to low platelets and impaired clotting. Pain management in DIC should use intravenous or oral routes to avoid bleeding complications, making this intervention unsafe for the client’s condition.

Choice D reason: Lemon-glycerin swabs for mouth care are not ideal in DIC, as they can dry mucous membranes, increasing bleeding risk in thrombocytopenic clients. Gentle oral care with saline or soft brushes is preferred to maintain mucosal integrity, making this intervention less appropriate for DIC management.

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A client has been diagnosed with thrombocytopenia. What are the primary nursing interventions while instituting corticosteroid therapy in this client?

Nursing Test Bank

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