A client with thrombocytopenia presents with petechiae, pallor, and weakness.
Which intervention should the nurse implement to address the client's symptoms?
Apply pressure to any bleeding site and elevate the affected area.
Administer plasma exchange therapy.
Monitor renal function and fluid balance.
Prepare the client for immunosuppressant therapy.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The presence of lymphadenopathy Lymphadenopathy refers to the enlargement of lymph nodes and is not a primary assessment finding to identify potential causes and types of thrombocytopenia.
While it may be relevant in some cases, it is not as prioritized as signs of infection or organ dysfunction.
Choice B rationale:
The patient's history of herbal supplements While the patient's history of herbal supplements is important to assess for potential causes of thrombocytopenia, it is not the most immediate assessment finding to prioritize.
Signs of infection or organ dysfunction are more crucial in the initial assessment as they may indicate acute and potentially life-threatening conditions.
Choice D rationale:
The size and shape of platelets on a peripheral blood smear The size and shape of platelets are important for diagnosing specific types of thrombocytopenia but are typically not the initial priority in the assessment.
Identifying signs of infection or organ dysfunction takes precedence because they can guide immediate intervention.
Correct Answer is B
Explanation
Choice A rationale:
"ITP results from decreased platelet production in the bone marrow." Rationale: This statement is not accurate.
Immune Thrombocytopenic Purpura (ITP) is primarily a disorder of platelet destruction, not decreased production in the bone marrow.
In ITP, autoantibodies target platelets, leading to their destruction by macrophages.
Choice B rationale:
"In ITP, autoantibodies mark platelets for destruction by macrophages." Rationale: This is the correct answer.
ITP is an autoimmune disorder where the immune system produces autoantibodies that attach to platelets, tagging them for destruction by macrophages in the spleen and liver.
Choice C rationale:
"ITP is characterized by impaired cleavage of von Willebrand factor." Rationale: This statement is not accurate.
Impaired cleavage of von Willebrand factor is a characteristic of von Willebrand disease, a different bleeding disorder, not ITP.
Choice D rationale:
"Thrombocytopenia in ITP is triggered by heparin-platelet factor 4 complexes." Rationale: This statement is incorrect.
Heparin-induced thrombocytopenia (HIT) involves the formation of antibodies against heparin-platelet factor 4 complexes, leading to platelet activation and a decrease in platelet count.
This is a different condition than ITP.
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