A patient undergoing chemotherapy after surgery develops thrombocytopenia. Which clinical finding should the nurse prioritize reporting to the healthcare provider?
Slightly elevated temperature of 37.8°C without other symptoms
Patient reports mild fatigue and weakness but no bleeding
Presence of petechiae and mucosal bleeding (eg, bleeding gums)
Platelet count decreased to 80.000/mm2 without any bleeding signs
The Correct Answer is C
Rationale:
A. Slightly elevated temperature of 37.8°C without other symptoms is incorrect because this finding is more concerning for infection (especially in neutropenia) rather than thrombocytopenia, and the temperature is only mildly elevated. While it should be monitored, it is not the priority related to low platelets.
B. Patient reports mild fatigue and weakness but no bleeding is incorrect because fatigue is a common, nonspecific side effect of chemotherapy and does not indicate an immediate complication of thrombocytopenia.
C. Presence of petechiae and mucosal bleeding (eg, bleeding gums) is correct because these are classic signs of thrombocytopenia and indicate an increased risk of significant bleeding. Active bleeding requires prompt reporting and intervention to prevent life-threatening hemorrhage.
D. Platelet count decreased to 80,000/mm² without any bleeding signs is incorrect because mild to moderate thrombocytopenia without bleeding is often monitored rather than urgently treated. The presence of bleeding is a higher priority than the laboratory value alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Superficial spreading melanoma usually presents as a variegated lesion with shades of brown, tan, or black, often with irregular borders and asymmetry. A purplish hue is not typical of this type of melanoma; lesions with purple tones may indicate vascular lesions (like hemangiomas) or rare cancers such as Kaposi sarcoma.
B. Early superficial spreading melanoma is typically painless. Pain is not a reliable indicator of early melanoma and usually only occurs if the lesion becomes ulcerated, infected, or grows deeply into the skin layers, which is more characteristic of advanced disease.
C. Melanoma is a malignant lesion, not an infection, so it does not normally produce pus. Purulent drainage would suggest a bacterial infection, abscess, or skin ulcer rather than a cancerous lesion.
D. Pruritus, or itching, is an expected finding in superficial spreading melanoma. Patients may notice mild irritation or tingling at the site of the lesion, often before any other changes are apparent. This symptom, combined with changes in size, color, shape, or the appearance of new moles, should alert the nurse to the possibility of melanoma and the need for further evaluation.
Correct Answer is A
Explanation
Rationale:
A. For women who menstruate, breast tissue changes throughout the menstrual cycle due to hormonal fluctuations. During the follicular phase (approximately one week after the start of menstruation), estrogen and progesterone levels are relatively low, causing the breasts to be less swollen, less tender, and less lumpy. Performing a breast self-exam at this time makes it easier to detect any abnormal masses or changes accurately and reduces discomfort during palpation. This timing is recommended by organizations such as the American Cancer Society.
B. Breast tissue is not uniform throughout the menstrual cycle. Random timing can result in palpating normal hormonal-related lumps or tenderness, leading to confusion, false alarms, or missed findings. Consistency in timing improves the reliability of self-exams.
C. On the first day of menstruation, breasts may be tender, swollen, or engorged due to fluid retention and hormonal shifts. This can make palpation uncomfortable and less accurate, increasing the likelihood of either missing a true abnormality or misidentifying normal tissue changes as a lump.
D. Two weeks before menstruation corresponds to the luteal phase, when progesterone peaks. This can lead to breast engorgement, nodularity, and tenderness, making lumps harder to distinguish from normal cyclic changes. Conducting a self-exam at this time is less reliable.
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