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 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.

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 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 experiencing spontaneous bleeding.Which statement best explains the potential cause of this bleeding?

Correct Answer is B

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 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?

(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 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?

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

A nurse is caring for a patient diagnosed with thrombocytopenia. What should the nurse include in the patient education regarding self-care measures?

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 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?