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: A sodium level of 140 mEq/L is within the normal range and not diagnostic of Addison’s disease. This condition, caused by adrenal insufficiency, typically leads to hyponatremia due to reduced aldosterone, which decreases sodium reabsorption, making a normal sodium level uncharacteristic of the disease.

Choice B reason: A glucose level of 100 mg/dL is normal and not specific to Addison’s disease. Hypoglycemia is more common due to cortisol deficiency, which impairs gluconeogenesis. A normal glucose level does not support the diagnosis, as it does not reflect the metabolic disruptions of adrenal insufficiency.

Choice C reason: A blood pressure of 135/90 mm Hg is elevated but not diagnostic of Addison’s disease. The condition typically causes hypotension due to reduced aldosterone and cortisol, leading to low blood volume and vascular tone. Hypertension suggests another etiology, not adrenal insufficiency.

Choice D reason: A potassium level of 6.0 mEq/L indicates hyperkalemia, a diagnostic sign of Addison’s disease. Aldosterone deficiency reduces potassium excretion in the kidneys, leading to elevated serum potassium. This, combined with hyponatremia and hypotension, is a hallmark of adrenal insufficiency, making hyperkalemia a key diagnostic finding.

A. An in-depth and real-time neurological assessment of the client’s condition B. The client’s level of knowledge about preceding events C. An assessment of the client’s current level of consciousness D. An assessment of the client’s lowest verbal and physical response to stimuli

Correct Answer is C

Explanation

Reasoning:

Choice A reason: The Glasgow Coma Scale (GCS) provides a standardized score for consciousness, not an in-depth neurological assessment. It evaluates eye, verbal, and motor responses but does not detail specific neurological deficits like cranial nerve function, requiring additional tests for a comprehensive neurological evaluation.

Choice B reason: The GCS does not assess knowledge of preceding events, which relates to memory or orientation, not consciousness. Amnesia or cognitive deficits are evaluated separately. The GCS focuses on immediate responses to stimuli, providing a snapshot of consciousness, not historical knowledge.

Choice C reason: The GCS assesses the client’s current level of consciousness by scoring eye opening, verbal response, and motor response. Trending scores over time indicates changes in consciousness, reflecting neurological status in conditions like head injury, guiding interventions and prognosis in critical care settings.

Choice D reason: The GCS does not measure the “lowest” verbal and physical response but the best response to stimuli at the time of assessment. It quantifies consciousness, not minimal function. Scores reflect current neurological status, not the worst possible responses, making this inaccurate.

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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

Naxlex Comprehensive Predictor Exams

The nurse assesses a client who has been diagnosed with Addison's disease. Which of the following is a diagnostic sign of this disease?

Correct Answer is D

Explanation

A nurse is reviewing the trend of a client’s scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client’s status?

Correct Answer is C

Explanation

A client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. Which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms?

The nurse is caring for a client with an exacerbation of sickle cell disease (SCD). Which finding indicates to the nurse that the client is experiencing a liver complication from this condition?

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Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a client with Cushing's syndrome?

Which endocrine disorder causes the client to have dilutional hyponatremia?