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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Reasoning:
Choice A reason: Decreased heart rate is a late sign in subdural hematoma, occurring with increased intracranial pressure (ICP) causing Cushing’s triad (bradycardia, hypertension, irregular breathing). Early manifestations like altered LOC appear first due to hematoma compression, making heart rate changes a secondary concern.
Choice B reason: Alteration in level of consciousness is the earliest manifestation of subdural hematoma. As the hematoma expands, it compresses brain tissue, impairing cerebral function, leading to confusion, lethargy, or reduced responsiveness. This precedes other signs like motor deficits or vital sign changes, making it the first to monitor.
Choice C reason: Slurred speech may occur in subdural hematoma if motor or speech areas are affected, but it is not the earliest sign. Altered LOC typically precedes focal neurological deficits, as hematoma compression globally impacts brain function before specific areas, making speech changes secondary.
Choice D reason: Bradycardia, like decreased heart rate, is a late sign in subdural hematoma, part of Cushing’s triad from severe ICP elevation. Early signs like altered LOC occur first due to initial brain compression, making bradycardia a later manifestation requiring urgent intervention.
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Oral temperature monitoring is important for detecting infection post-surgery but is not the primary concern in transsphenoidal hypophysectomy. Cushing’s syndrome causes hyperglycemia due to cortisol-induced insulin resistance, and surgical stress may exacerbate this, making glucose monitoring more critical than temperature in the perioperative period.
Choice B reason: Weight monitoring is relevant for long-term Cushing’s syndrome management due to fat redistribution, but it is not the most critical during surgery. Perioperative stress and fluid shifts have minimal immediate impact on weight, whereas glucose fluctuations from cortisol changes are more acute and require close monitoring.
Choice C reason: Assessing urine for blood is not a priority in transsphenoidal hypophysectomy. This surgery involves the pituitary gland, not the urinary tract, so hematuria is unlikely. Blood glucose fluctuations, driven by cortisol changes and surgical stress, are a more immediate concern requiring vigilant monitoring.
Choice D reason: Blood glucose monitoring is critical before, during, and after transsphenoidal hypophysectomy. Cushing’s syndrome causes hyperglycemia due to cortisol-induced insulin resistance. Surgery may alter cortisol levels, exacerbating glucose fluctuations, and postoperative adrenal insufficiency risk necessitates close glucose monitoring to manage metabolic complications effectively.
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