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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

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.

A. Fever. B. Confusion. C. Swelling of affected limbs. D. Blood in stool (hematochezia) E. Elevated liver function tests (ALT and AST)

Correct Answer is ["B","C","D"]

Explanation

Confusion.

C. Swelling of affected limbs.

D. Blood in stool (hematochezia)

Choice A rationale:

Fever.

Rationale: Fever is not typically associated with thrombocytopenia itself.

Thrombocytopenia primarily affects the platelet count and can result in bleeding symptoms, but fever is not a direct symptom of thrombocytopenia.

Choice B rationale:

Confusion.

Rationale: Confusion can be a symptom of thrombocytopenia, especially if bleeding occurs in the brain, leading to neurological symptoms.

Thrombocytopenia can cause intracranial bleeding, which may result in confusion and altered mental status.

Choice C rationale:

Swelling of affected limbs.

Rationale: Swelling of affected limbs is not a common symptom of thrombocytopenia.

Thrombocytopenia primarily leads to bleeding symptoms, such as easy bruising, petechiae, or hematomas, rather than swelling.

Choice D rationale:

Blood in stool (hematochezia)

Rationale: Blood in stool (hematochezia) is a potential symptom of thrombocytopenia.

When platelet counts are low, it can lead to gastrointestinal bleeding, which may manifest as blood in the stool.

Choice E rationale:

Elevated liver function tests (ALT and AST)

Rationale: Elevated liver function tests (ALT and AST) are not typically associated with thrombocytopenia.

Thrombocytopenia is primarily related to platelet counts, while elevated liver function tests suggest liver dysfunction, which may have different causes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client with thrombocytopenia presents with petechiae, pallor, and weakness.Which intervention should the nurse implement to address the client's symptoms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with thrombocytopenia is experiencing spontaneous bleeding.Which statement best explains the potential cause of this bleeding?

Correct Answer is B

Explanation

(Select all that apply):A nurse is assessing a patient with suspected thrombocytopenia.Which findings should the nurse consider as potential signs or symptoms of thrombocytopenia? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a patient with thrombocytopenia.Which statement accurately describes the pathophysiology of immune thrombocytopenic purpura (ITP)?

A client with thrombocytopenia experiences prolonged bleeding even after minor trauma.What statement by the nurse accurately explains the relationship between platelet count and bleeding risk?

A nurse is caring for a patient with thrombocytopenia.The patient reports experiencing hematochezia, fatigue, and abdominal pain.What should the nurse prioritize in the assessment of this patient?

A client with thrombocytopenia presents with petechiae, pallor, and weakness.Which intervention should the nurse implement to address the client's symptoms?

A client with thrombocytopenia is at risk of bleeding complications.Which nursing intervention is essential to prevent and manage bleeding in this client?

A client has developed thrombocytopenia following chemotherapy.What is the likely cause of thrombocytopenia in this patient?

A nurse is caring for a patient diagnosed with thrombocytopenia. What should the nurse include in the patient education regarding self-care measures?

(Select all that apply):A nurse is providing care to a patient with thrombocytopenia.Which nursing interventions are appropriate for this patient? Select all that apply.

A client with thrombocytopenia presents with petechiae, pallor, and weakness.
Which intervention should the nurse implement to address the client's symptoms?