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?

Monitoring the patient's neurological status.

Checking the patient's vital signs.

Administering corticosteroids.

Preparing the patient for a splenectomy.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Monitoring the patient's neurological status While monitoring neurological status is important in patient care, it is not the immediate priority when a patient with thrombocytopenia reports hematochezia (bloody stools), fatigue, and abdominal pain.

Checking vital signs helps assess the patient's overall stability and guides immediate interventions.

Choice C rationale:

Administering corticosteroids Administering corticosteroids may be a treatment option for certain types of thrombocytopenia, but it is not the initial priority in the assessment of a patient presenting with hematochezia, fatigue, and abdominal pain.

First, the nurse needs to assess the patient's condition and vital signs to determine the severity of the situation.

Choice D rationale:

Preparing the patient for a splenectomy Preparing a patient for a splenectomy is a significant intervention and should not be the initial priority in this case.

It may be considered as a treatment option in some cases of thrombocytopenia, but it should not take precedence over assessing the patient's vital signs and overall condition.

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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. Administer platelet transfusion. B. Encourage high-intensity physical activity. C. Monitor for signs of bleeding. D. Administer heparin therapy. E. Educate the patient on infection prevention.

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.

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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?

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

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

(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.

(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 schistocytes on the peripheral blood smear.What does the presence of schistocytes indicate, and how should the nurse interpret this finding?

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

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

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?