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 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.

A. The presence of lymphadenopathy. B. The patient's history of herbal supplements. C. Signs of infection or organ dysfunction. D. The size and shape of platelets on a peripheral blood smear.

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.

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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

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

Correct Answer is D

Explanation

A nurse is conducting a physical examination of a patient suspected of having thrombocytopenia. What assessment findings should the nurse prioritize to identify potential causes and types of thrombocytopenia?

Correct Answer is C

Explanation

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

A nurse is educating a patient and their family about thrombocytopenia.Which statement accurately describes the normal platelet count range?

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 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?

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

(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.

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