A nurse is caring for a patient with thrombocytopenia.
Which statement accurately describes the pathophysiology of immune thrombocytopenic purpura (ITP)?
"ITP results from decreased platelet production in the bone marrow.”
"In ITP, autoantibodies mark platelets for destruction by macrophages.”
"ITP is characterized by impaired cleavage of von Willebrand factor.”
"Thrombocytopenia in ITP is triggered by heparin-platelet factor 4 complexes.”
The Correct Answer is B
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
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.
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