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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale

Referring the client to see an optometrist is inappropriate because visual disturbances can be a sign of digoxin toxicity, which requires immediate medical attention rather than routine visual examination. Toxicity manifests due to elevated serum digoxin levels, with symptoms including blurred vision and yellow-green halos. Normal digoxin range is 0.5-2.0 ng/mL.

Choice B rationale

Asking if the client wears glasses or contact lenses does not address the root cause of visual disturbances, which is likely linked to digoxin toxicity. Such queries delay prompt medical intervention needed to evaluate and manage the client’s condition. Ocular aids are unrelated to pharmacological adverse effects.

Choice C rationale

Obtaining a prescription for stat laboratory tests is essential for assessing serum digoxin levels and electrolytes, particularly potassium, as hypokalemia increases sensitivity to digoxin toxicity. Prompt identification of toxicity allows timely interventions, including discontinuation of digoxin or administration of antidotes like Digibind.

Choice D rationale

Obtaining the client’s blood pressure is irrelevant in this scenario, as visual disturbances are not indicative of blood pressure abnormalities but rather digoxin toxicity. Immediate focus should be on confirming and managing toxicity through laboratory evaluation and clinical assessment.

A. Teaching the client preventive measures. B. Preventing progression to complications. C. Educating the client about the treatment. D. Providing pain management.

Correct Answer is B

Explanation

Choice A rationale

Teaching preventive measures, like proper hydration and hygiene, is integral for long-term UTI management but not the immediate clinical priority. Effective prevention helps reduce recurrence rates but does not address acute infection or associated complications during the current episode.

Choice B rationale

Preventing progression to complications takes priority in lower UTIs. This includes early and appropriate antibiotic therapy to inhibit bacterial proliferation and monitoring for symptoms suggestive of an ascending infection. Left untreated, lower UTIs can progress to pyelonephritis, a serious condition that increases morbidity.

Choice C rationale

Educating about treatment ensures compliance with the prescribed antibiotics and symptom management strategies. While necessary, client education is more aligned with secondary interventions after addressing the urgent need to prevent complications from the infection itself.

Choice D rationale

Pain management is important to alleviate discomfort and improve the client’s quality of life. However, addressing pain without resolving the underlying infection risks further complications. Thus, pain control, while valuable, is not the critical first-line intervention for preventing clinical deterioration. .

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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?

Nursing Test Bank

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