The nurse is caring for a client with thrombocytopenia whose platelet level is 18,000/mm³. Which of the following assessment findings should the nurse expect?
Reports of fatigue.
Hemorrhage.
Petechiae.
Reports of headache.
The Correct Answer is B
Choice A rationale
Fatigue can occur in thrombocytopenia due to associated bleeding or anemia, but it is not a hallmark symptom specific to low platelet counts alone. Fatigue relates more to overall systemic effects or concurrent conditions rather than isolated thrombocytopenia. Hemorrhage and petechiae, however, are more directly correlated with reduced platelets in circulation, which compromise clotting and vascular integrity.
Choice B rationale
Hemorrhage is a major concern in thrombocytopenia due to severely reduced platelet counts. Normal platelet levels range from 150,000–450,000/mm³, and values of 18,000/mm³ indicate critical impairment in clot formation, increasing the risk of spontaneous bleeding. Hemorrhagic events in vital organs pose life-threatening consequences, making monitoring and interventions essential to minimize complications associated with uncontrolled bleeding.
Choice C rationale
Petechiae are pinpoint hemorrhages visible on the skin or mucosal surfaces, indicating capillary bleeding due to insufficient platelet-mediated clotting. Normal platelet levels maintain vascular integrity by enabling clot formation, which prevents such microvascular bleeding. Platelet counts as low as 18,000/mm³ lead to abnormal hemorrhagic manifestations, making petechiae a frequent and observable sign in severe thrombocytopenia cases.
Choice D rationale
Headache can occur with thrombocytopenia if intracranial hemorrhage develops, but it is not an expected symptom in all cases. While bleeding risks elevate overall concerns, headache depends on specific organ involvement. Petechiae and systemic hemorrhage are primary symptoms associated with low platelet levels. Headaches without evidence of bleeding do not distinctly correlate with thrombocytopenia diagnosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Thrombopoiesis, the process of platelet production, is not typically a direct cause of secondary immune thrombocytopenic purpura. This condition often stems from an underlying immune or viral trigger rather than bone marrow dysfunction.
Choice B rationale
HIV is a recognized cause of secondary ITP due to immune dysregulation and increased platelet destruction. It is essential to test for HIV in clients with newly diagnosed ITP to identify and manage the underlying condition effectively.
Choice C rationale
Hepatitis C virus is a common trigger for secondary ITP due to immune complex formation and platelet destruction. Testing for HCV is crucial for clients with thrombocytopenia to establish a precise etiology and guide treatment.
Choice D rationale
Von Willebrand disease primarily affects von Willebrand factor and is associated with qualitative or quantitative clotting issues rather than platelet destruction or secondary ITP. It is not routinely tested in this context.
Choice E rationale
Hemophilia B involves Factor IX deficiency leading to bleeding disorders but does not relate to immune-mediated platelet destruction. Testing for hemophilia B is irrelevant in clients suspected of secondary ITP.
Correct Answer is D
Explanation
Choice A rationale
Hypotension is not a typical sign of fluid overload. Fluid overload often presents with hypertension due to increased circulatory volume. Monitoring blood pressure is essential, but hypotension does not reliably indicate fluid overload. This option does not align with scientific understanding of fluid overload symptoms.
Choice B rationale
Distention above the pubis area suggests urinary retention or bladder distension rather than fluid overload. While important to assess, it does not directly indicate fluid overload. This symptom is more related to mechanical issues than systemic fluid imbalance and volume overload.
Choice C rationale
Hypernatremia is not a sign of fluid overload. Fluid overload typically results in dilutional hyponatremia, where excessive fluids lower sodium levels. Monitoring sodium levels is useful, but hypernatremia would suggest dehydration or other conditions, not excess fluid volume. This choice is inconsistent with scientific knowledge.
Choice D rationale
Maintaining strict intake and output records is a fundamental approach to monitoring fluid balance. Accurate measurements of fluid intake and output help detect fluid overload early. This method directly correlates with assessing excess fluid volume in clinical practice. It is a reliable, evidence-based intervention for monitoring fluid status. .
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