A client with thrombocytopenia is experiencing spontaneous bleeding.
Which statement best explains the potential cause of this bleeding?
"Spontaneous bleeding in thrombocytopenia is due to excessive clotting.”
"Immune-mediated destruction of platelets leads to spontaneous bleeding.”
"Bleeding occurs in thrombocytopenia due to increased platelet production.”
"Thrombocytopenia-related bleeding is a result of heparin therapy.”
The Correct Answer is B
Choice A rationale:
"Spontaneous bleeding in thrombocytopenia is due to excessive clotting." Rationale: This statement is not accurate.
Thrombocytopenia is characterized by a low platelet count, which impairs the blood's ability to form clots.
Spontaneous bleeding occurs because there are not enough platelets to participate in clot formation.
Choice B rationale:
"Immune-mediated destruction of platelets leads to spontaneous bleeding." Rationale: This is the correct answer.
In thrombocytopenia, especially immune thrombocytopenic purpura (ITP), the immune system destroys platelets, leading to a decreased platelet count.
This makes the patient more prone to spontaneous bleeding.
Choice C rationale:
"Bleeding occurs in thrombocytopenia due to increased platelet production." Rationale: This statement is incorrect.
Thrombocytopenia is characterized by a decreased platelet count, not increased production.
Choice D rationale:
"Thrombocytopenia-related bleeding is a result of heparin therapy." Rationale: This statement is inaccurate.
Thrombocytopenia related to heparin therapy is known as heparin-induced thrombocytopenia (HIT), and it occurs due to an immune response to heparin, not the same mechanism as in thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
"Administer platelet transfusion." Rationale: This is an appropriate intervention for a patient with thrombocytopenia, especially if they are experiencing severe bleeding or have a very low platelet count.
Platelet transfusion can help increase the platelet count and prevent or stop bleeding.
Choice B rationale:
"Encourage high-intensity physical activity." Rationale: This intervention is not appropriate for a patient with thrombocytopenia.
High-intensity physical activity can increase the risk of bleeding in these patients due to the low platelet count.
Choice C rationale:
"Monitor for signs of bleeding." Rationale: This is an essential intervention for a patient with thrombocytopenia.
Monitoring for signs of bleeding, such as petechiae, ecchymosis, or mucosal bleeding, allows for early detection and intervention.
Choice D rationale:
"Administer heparin therapy." Rationale: This intervention is not appropriate for a patient with thrombocytopenia, especially if the thrombocytopenia is immune-mediated, as heparin can exacerbate the condition.
Choice E rationale:
"Educate the patient on infection prevention." Rationale: This is an appropriate intervention for a patient with thrombocytopenia.
Patients with low platelet counts are at increased risk of infection, so education on infection prevention measures, such as hand hygiene and avoiding sick individuals, is essential.
Correct Answer is B
Explanation
Choice A rationale:
"Increased platelet production due to chemotherapy." Rationale: This statement is not accurate.
Chemotherapy often suppresses bone marrow function, leading to a decrease in platelet production, not an increase.
Thrombocytopenia is a common side effect of chemotherapy due to reduced platelet production.
Choice B rationale:
"Immune-mediated platelet destruction caused by chemotherapy." Rationale: This statement is correct.
Thrombocytopenia in patients undergoing chemotherapy is often due to immune-mediated platelet destruction.
Chemotherapy can trigger an autoimmune response, leading to the destruction of platelets by the immune system.
Choice C rationale:
"Thrombocytopenia in this case is unrelated to chemotherapy." Rationale: This statement is unlikely to be true.
Thrombocytopenia occurring in a patient following chemotherapy is often directly related to the treatment.
While other factors may contribute, chemotherapy is a known cause of decreased platelet counts.
Choice D rationale:
"Thrombocytopenia results from the inhibition of platelet aggregation by chemotherapy." Rationale: This statement is not accurate.
Chemotherapy primarily affects platelet production and can lead to a decrease in platelet count.
It does not typically inhibit platelet aggregation.
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