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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Receiving pneumococcal and influenza vaccines is crucial for patients with sickle cell disease. Infections can trigger sickle cell crises, and these vaccines help prevent common infections that could lead to complications. Ensuring immunization against these diseases reduces the risk of crisis and hospitalization.
Choice B reason: Taking oral hydroxyurea as ordered is an important strategy for preventing sickle cell crises. Hydroxyurea increases fetal hemoglobin levels, which reduces the occurrence of sickling in red blood cells. Adherence to this medication regimen helps reduce the frequency of painful episodes and other complications associated with sickle cell disease.
Choice C reason: Avoiding dehydration is essential for patients with sickle cell disease. Dehydration can lead to increased blood viscosity, promoting sickling of red blood cells and triggering a crisis. Staying well-hydrated helps maintain proper blood flow and reduces the risk of sickle cell-related complications.
Choice D reason: Following a low-fat, low-sodium diet is generally beneficial for overall health but is not specifically targeted at preventing sickle cell crises. While maintaining a healthy diet is important, the focus for sickle cell patients should be on hydration, infection prevention, and medication adherence.
Correct Answer is A
Explanation
Choice A reason: The patient being increasingly drowsy and hard to arouse is an urgent finding that should be reported immediately. This condition may indicate intracranial bleeding or other severe complications related to extremely low platelet count (10,000/mm³) in idiopathic thrombocytopenic purpura (ITP). Immediate medical intervention is required to prevent further deterioration.
Choice B reason: Red, raised purpura on the patient's feet and hands is a concerning finding indicative of significant thrombocytopenia, but it is not as immediately life-threatening as decreased consciousness. It should still be monitored and managed, but the priority is the patient's level of consciousness.
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