A nurse is caring for a patient with thrombocytopenia.
The patient presents with mucosal bleeding, including petechiae, purpura, and gingival bleeding.
What should the nurse anticipate when assessing this patient's platelet count?
The platelet count is likely within the normal range.
The platelet count may be below 50,000/uL, indicating a risk of prolonged bleeding.
The platelet count is typically above 100,000/uL in thrombocytopenia.
The platelet count does not affect bleeding symptoms.
The Correct Answer is B
Choice A rationale:
"The platelet count is likely within the normal range." Rationale: This statement is unlikely to be true.
Given that the patient is presenting with mucosal bleeding, including petechiae, purpura, and gingival bleeding, it suggests a potential problem with platelet function.
Platelet counts within the normal range do not typically lead to these bleeding symptoms.
Choice B rationale:
"The platelet count may be below 50,000/uL, indicating a risk of prolonged bleeding." Rationale: This statement is accurate.
The symptoms described (petechiae, purpura, and gingival bleeding) are indicative of thrombocytopenia, where the platelet count is typically below 50,000/uL.
This lower count increases the risk of prolonged bleeding and bruising.
Choice C rationale:
"The platelet count is typically above 100,000/uL in thrombocytopenia." Rationale: This statement is not accurate.
Thrombocytopenia is characterized by a decrease in platelet count, often below 100,000/uL, as seen in choice B.
A platelet count above 100,000/uL is not typical in thrombocytopenia.
Choice D rationale:
"The platelet count does not affect bleeding symptoms." Rationale: This statement is incorrect.
Platelet count plays a significant role in the body's ability to form blood clots and prevent bleeding.
Low platelet counts can lead to bleeding symptoms, as described in the patient's presentation of mucosal bleeding.
Platelet count is indeed relevant in assessing and managing bleeding risk in thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Administer platelet transfusions for life-threatening hemorrhage.
Platelet transfusions are typically administered in cases of severe thrombocytopenia where the risk of life-threatening hemorrhage is high.
However, it is not appropriate to administer platelet transfusions routinely or without a specific indication.
Therefore, this choice is not applicable in all cases of thrombocytopenia.
Choice B rationale:
Discontinue heparin immediately if signs of thrombosis are present.
In patients with thrombocytopenia, the use of heparin can increase the risk of bleeding.
If signs of thrombosis (clot formation) occur while a patient is on heparin, it is crucial to discontinue the medication promptly to prevent further clot formation.
This is a necessary intervention in such cases.
Choice C rationale:
Teach the patient to avoid NSAIDs, aspirin, and alcohol.
Patients with thrombocytopenia have a reduced number of platelets, which are essential for blood clotting.
NSAIDs (nonsteroidal anti-inflammatory drugs), aspirin, and alcohol can further increase the risk of bleeding by interfering with platelet function or causing irritation to the gastrointestinal tract.
Therefore, it is essential to educate patients to avoid these substances to minimize bleeding risks.
Choice D rationale:
Administer corticosteroids, IVIG, anti-D antibody, or rituximab as prescribed.
These treatments may be prescribed in specific cases of thrombocytopenia, depending on the underlying cause.
Corticosteroids can help reduce immune-mediated destruction of platelets, IVIG (intravenous immunoglobulin) can boost platelet levels, anti-D antibody is used in Rh-positive individuals with Rh-negative platelets, and rituximab may be prescribed for certain autoimmune causes of thrombocytopenia.
The administration of these medications is based on the patient's specific diagnosis and medical orders.
Choice E rationale:
Monitor the patient's response to treatment by checking the skin color and temperature.
While monitoring the patient's response to treatment is essential, checking skin color and temperature alone may not provide comprehensive information about thrombocytopenia management.
Monitoring platelet counts, signs of bleeding, and other relevant laboratory parameters would be more specific and valuable in assessing the effectiveness of treatment.
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