A nurse is developing a care plan for a patient who has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which of the following symptoms is most important for the nurse to monitor?
Elevated WBC count.
Fever.
Ecchymosis.
Fatigue.
The Correct Answer is C
Choice A rationale
While an elevated WBC count can indicate an infection, it is not the most important symptom to monitor in a patient with idiopathic thrombocytopenic purpura (ITP). ITP is primarily a platelet disorder, and while infection can trigger or exacerbate the condition, an elevated WBC count is not a direct symptom of ITP78.
Choice B rationale
Fever can be a sign of infection, which can trigger or exacerbate ITP. However, it is not the most important symptom to monitor in a patient with ITP78.
Choice C rationale
Ecchymosis, or bruising, is a key symptom of ITP. Because ITP involves a decrease in platelets, which are necessary for clotting, patients with this condition are prone to bruising and bleeding. Therefore, monitoring for ecchymosis is crucial.
Choice D rationale
Fatigue can be a symptom of ITP, but it is not the most important symptom to monitor. While fatigue can impact a patient’s quality of life, it does not directly indicate the severity of the condition.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
The task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.
Choice B rationale
Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.
Choice C rationale
Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.
Choice D rationale
Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.
Correct Answer is B
Explanation
Choice B rationale
The normal respiratory rate for a newborn is between 30 and 60 breaths per minute. Therefore, a respiratory rate of 48 breaths per minute is within the expected reference range for a newborn.
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