A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?
Petechiae on the oral mucosa.
Hemoglobin of 14 g/dL.
Bleeding of the gums after oral care.
Pain and swelling in one leg.
The Correct Answer is D
A. Petechiae are tiny, pinpoint, red or purple spots on the skin or mucous membranes, caused by bleeding under the skin. While petechiae can indicate bleeding, they are not specific to HIT and can occur due to various reasons, including low platelet count or coagulation disorders. They do not necessarily indicate thrombotic complications associated with HIT.
B. This hemoglobin level is within the normal range for adults and does not directly correlate with HIT. However, it is important to monitor hemoglobin levels in patients with HIT due to the risk of bleeding and thrombosis.
C. Bleeding gums can occur due to various reasons, including gum disease or thrombocytopenia (low platelet count). In HIT, the concern is not just bleeding but also the paradoxical risk of thrombosis despite low platelet counts. Bleeding from mucosal surfaces can indicate underlying thrombocytopenia but does not specifically highlight the thrombotic risk of HIT.
D. This symptom is concerning for deep vein thrombosis (DVT), which is a thrombotic complication associated with HIT. HIT predisposes patients to thrombosis due to the formation of antibodies against
platelet factor 4/heparin complexes, leading to platelet activation and clot formation. DVT is a serious complication that requires immediate intervention to prevent pulmonary embolism (PE).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. During chemotherapy, many patients experience nausea, vomiting, and changes in taste or appetite. Spicy and highly-seasoned foods can exacerbate gastrointestinal symptoms and may not be well tolerated. It's generally recommended to encourage bland, easy-to-digest foods to help maintain adequate nutrition and reduce discomfort.
B. Loperamide is not used to prevent nausea; rather, it is an antidiarrheal medication used to treat diarrhea, which can be a side effect of chemotherapy. Nausea prevention is typically managed with antiemetic medications such as ondansetron, metoclopramide, or others prescribed based on the patient's specific needs and chemotherapy regimen.
C. Pain management is an essential aspect of caring for oncology patients, including those receiving chemotherapy. Cancer and its treatment can cause pain directly or indirectly (such as from procedures or complications). Regular and thorough pain assessments allow for timely intervention and improvement in the client's comfort and quality of life.
D. Chemotherapy medications are typically administered through central venous access devices (e.g., central lines, PICC lines) rather than through peripheral veins. This is because chemotherapy drugs can be vesicants (causing tissue damage if they leak out of the vein) or irritants to smaller peripheral veins.
Using a larger gauge peripheral line (e.g., 18 gauge) is not standard practice for administering chemotherapy due to the potential risks and complications associated with peripheral administration.
Correct Answer is A
Explanation
A. Retropulsion is a classic manifestation of postural instability in Parkinson's disease. It refers to a tendency to lose balance and fall backward, especially when attempting to initiate walking or when challenged with external forces.
B. Impaired handwriting, also known as micrographia, is associated with bradykinesia (slowness of movement) in Parkinson's disease. It manifests as progressively smaller and more cramped handwriting.
C. Muscle soreness and pain can occur in Parkinson's disease, but they are not typically directly associated with postural instability. They may occur due to rigidity (muscle stiffness) or abnormal postures maintained over time.
D. Slow movements, or bradykinesia, are a hallmark feature of Parkinson's disease and are characterized by a gradual reduction in the speed and fluidity of voluntary movements. While related to motor symptoms in Parkinson's disease, slow movements are not specific to postural instability.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.