The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP) whose platelet count is 10,000/mm³. What assessment finding will the nurse report to the provider immediately?
The patient has scattered petechiae on bilateral lower extremities.
The patient has ecchymosis around their intravenous site.
The Correct Answer is B
Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.
Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Adhering to the medication regimen even when not experiencing symptoms is crucial for managing multiple sclerosis (MS). MS is a chronic condition that requires consistent treatment to prevent relapses and slow disease progression. This statement indicates proper understanding of medication adherence.
Choice B reason: Maintaining regular physical activity and exercise with planned rest periods is important for managing MS. Physical activity helps maintain muscle strength, flexibility, and overall health, while planned rest periods prevent overexertion and fatigue. This statement indicates proper understanding of balancing activity and rest.
Choice C reason: Soaking in a hot bath every night to help with muscle weakness and fatigue requires further teaching. Heat can exacerbate MS symptoms, leading to increased fatigue and muscle weakness. Patients with MS are often advised to avoid hot baths and instead use cool or lukewarm water for comfort. This statement indicates a misunderstanding of how to manage symptoms effectively.
Choice D reason: Identifying strategies to control anxiety and physical stress to prevent exacerbations is important for managing MS. Stress can trigger MS relapses and worsen symptoms. Developing stress management techniques helps reduce the risk of exacerbations. This statement indicates proper understanding of the importance of stress management.
Correct Answer is A
Explanation
Choice A reason: Ondansetron is an antiemetic given to control nausea and vomiting, which are common symptoms in patients with inflammatory bowel disease, especially when they have a flare-up.
Choice B reason: Vitamin B12 injections are crucial for preventing pernicious anemia but are not specific treatments for acute management of inflammatory bowel disease symptoms.
Choice C reason: Antidiarrheal medications should be used cautiously in inflammatory bowel disease as they can worsen symptoms or lead to complications like toxic megacolon.
Choice D reason: Beta-adrenergic blockers are not used to reduce bowel motility and are not a part of the standard treatment regimen for inflammatory bowel disease.
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