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.

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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.

A. "Spontaneous bleeding in thrombocytopenia is due to excessive clotting.” B. "Immune-mediated destruction of platelets leads to spontaneous bleeding.” C. "Bleeding occurs in thrombocytopenia due to increased platelet production.” D. "Thrombocytopenia-related bleeding is a result of heparin therapy.”

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.

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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

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

Correct Answer is ["A","C","E"]

Explanation

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

Correct Answer is B

Explanation

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