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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Delaying follow-up without immediate intervention may result in the client's blood pressure remaining uncontrolled, increasing the risk of complications like cardiovascular events. Reevaluation in one month without assessing adherence neglects the urgent need for optimizing management.
Choice B rationale
Assessing adherence to both lifestyle modifications and medication therapy is crucial as noncompliance may explain the suboptimal blood pressure control. Ensuring adherence and addressing any barriers are necessary steps in evaluating the effectiveness of treatment.
Choice C rationale
Increasing medication dosage without first assessing the client's adherence to current prescriptions or lifestyle modifications may be premature. Nonadherence to therapy could render dosage adjustments ineffective, leading to unnecessary changes to the regimen.
Choice D rationale
Adding a calcium-channel blocker without assessing adherence disregards the importance of compliance. Treatment should be optimized based on existing therapy before considering additional pharmacological interventions. .
Correct Answer is B
Explanation
Choice A rationale
Teaching preventive measures is important for reducing recurrence of urinary tract infections (UTIs). These measures may include proper hydration, perineal hygiene, and urinating after intercourse. However, addressing preventive strategies is a long-term consideration and not the immediate priority for managing the active infection or preventing acute complications.
Choice B rationale
Preventing progression to complications is the priority in lower UTIs to avoid upper urinary tract involvement, such as pyelonephritis. This involves timely antibiotic administration and monitoring for signs like fever, flank pain, or worsening urinary symptoms. Pyelonephritis can lead to systemic complications like sepsis, making prevention critical to client safety.
Choice C rationale
Educating about treatment, such as the prescribed antibiotics and their potential side effects, ensures adherence and understanding. While valuable, it does not take precedence over immediate measures to halt disease progression or complications. Education supports long-term management but follows urgent clinical priorities.
Choice D rationale
Pain management is essential for comfort, addressing dysuria or pelvic pain associated with UTIs. Methods include analgesics like phenazopyridine. However, it is a supportive measure rather than a critical intervention for preventing complications, making it secondary to stopping the progression of the infection.
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