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?

The presence of lymphadenopathy.

The patient's history of herbal supplements.

Signs of infection or organ dysfunction.

The size and shape of platelets on a peripheral blood smear.

Answer and Explanation

The Correct Answer is C

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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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.

A. Administer platelet transfusions for life-threatening hemorrhage. B. Discontinue heparin immediately if signs of thrombosis are present. C. Teach the patient to avoid NSAIDs, aspirin, and alcohol. D. Administer corticosteroids, IVIG, anti-D antibody, or rituximab as prescribed. E. Monitor the patient's response to treatment by checking the skin color and temperature.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:

Administer platelet transfusions for life-threatening hemorrhage.

Platelet transfusions are typically administered in cases of severe thrombocytopenia where the risk of life-threatening hemorrhage is high.

However, it is not appropriate to administer platelet transfusions routinely or without a specific indication.

Therefore, this choice is not applicable in all cases of thrombocytopenia.

Choice B rationale:

Discontinue heparin immediately if signs of thrombosis are present.

In patients with thrombocytopenia, the use of heparin can increase the risk of bleeding.

If signs of thrombosis (clot formation) occur while a patient is on heparin, it is crucial to discontinue the medication promptly to prevent further clot formation.

This is a necessary intervention in such cases.

Choice C rationale:

Teach the patient to avoid NSAIDs, aspirin, and alcohol.

Patients with thrombocytopenia have a reduced number of platelets, which are essential for blood clotting.

NSAIDs (nonsteroidal anti-inflammatory drugs), aspirin, and alcohol can further increase the risk of bleeding by interfering with platelet function or causing irritation to the gastrointestinal tract.

Therefore, it is essential to educate patients to avoid these substances to minimize bleeding risks.

Choice D rationale:

Administer corticosteroids, IVIG, anti-D antibody, or rituximab as prescribed.

These treatments may be prescribed in specific cases of thrombocytopenia, depending on the underlying cause.

Corticosteroids can help reduce immune-mediated destruction of platelets, IVIG (intravenous immunoglobulin) can boost platelet levels, anti-D antibody is used in Rh-positive individuals with Rh-negative platelets, and rituximab may be prescribed for certain autoimmune causes of thrombocytopenia.

The administration of these medications is based on the patient's specific diagnosis and medical orders.

Choice E rationale:

Monitor the patient's response to treatment by checking the skin color and temperature.

While monitoring the patient's response to treatment is essential, checking skin color and temperature alone may not provide comprehensive information about thrombocytopenia management.

Monitoring platelet counts, signs of bleeding, and other relevant laboratory parameters would be more specific and valuable in assessing the effectiveness of treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with thrombocytopenia presents with petechiae, pallor, and weakness.Which intervention should the nurse implement to address the client's symptoms?

Correct Answer is A

Explanation

(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.

Correct Answer is ["B","C","D"]

Explanation

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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?