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
Explanation
Choice B rationale:
Administer plasma exchange therapy Administering plasma exchange therapy may be indicated in some cases of thrombocytopenia, but it is not the initial intervention when a client presents with petechiae, pallor, and weakness.
The primary concern in this situation is addressing active bleeding, which is best managed by applying pressure to bleeding sites and elevating the affected area.
Choice C rationale:
Monitor renal function and fluid balance While monitoring renal function and fluid balance is important in the overall care of a client with thrombocytopenia, it is not the immediate intervention when the client presents with symptoms of bleeding and weakness.
The priority is to stop the bleeding by applying pressure and elevating the affected area.
Choice D rationale:
Prepare the client for immunosuppressant therapy Immunosuppressant therapy may be considered as a treatment option for certain types of thrombocytopenia, but it is not the initial intervention when the client has active bleeding and weakness.
The immediate focus should be on bleeding control and symptom management.
Correct Answer is D
Explanation
Choice A rationale:
Administering alternative anticoagulants.
Administering alternative anticoagulants is not the primary intervention for preventing or managing bleeding in a client with thrombocytopenia.
Anticoagulants may increase the risk of bleeding in such patients and are generally not indicated unless there is a specific medical reason to use them.
Choice B rationale:
Preparing the client for splenectomy.
Splenectomy is not typically performed as a preventive measure for bleeding in thrombocytopenic patients.
While splenectomy may be considered in some cases of immune thrombocytopenia, it is not the essential nursing intervention to prevent or manage bleeding in most clients with thrombocytopenia.
Choice C rationale:
Avoiding platelet transfusions.
Avoiding platelet transfusions is not a recommended intervention in clients with thrombocytopenia who are at risk of bleeding complications.
Platelet transfusions are often necessary to raise platelet levels and prevent or manage bleeding in these individuals.
Choice D rationale:
Applying pressure to any bleeding site and elevating the affected area.
This is the essential nursing intervention to prevent and manage bleeding in clients with thrombocytopenia.
Applying pressure to a bleeding site helps control bleeding, and elevating the affected area can reduce swelling and minimize bleeding.
It is a fundamental measure in the care of thrombocytopenic clients.
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