The nurse is obtaining the health history from a client who was admitted with a platelet defect.
Which of the following information should be a priority for the nurse to obtain?
Reports of ecchymosis or wet purpura.
Any upcoming dental or invasive procedure appointments.
Over-the-counter and prescription medication use.
Family and genetic history.
The Correct Answer is C
Choice A rationale
Ecchymosis and wet purpura indicate abnormal bleeding tendencies often observed in platelet defects. While these findings are relevant, they are secondary to identifying medications that could exacerbate platelet dysfunction. Medication history directly influences the management plan by addressing reversible causes of thrombocytopenia, emphasizing its priority over descriptive bleeding symptoms.
Choice B rationale
Upcoming dental or invasive procedures are relevant to thrombocytopenia risks due to potential bleeding complications. However, these appointments do not provide immediate insight into causative factors of the platelet defect. Determining medication use offers direct information regarding drug-related impacts on platelet function, prioritizing it for management and diagnostic purposes over procedural risks.
Choice C rationale
Over-the-counter and prescription medication use are critical to evaluate because certain drugs can induce or worsen platelet defects. For example, NSAIDs like aspirin inhibit platelet aggregation and contribute to bleeding risks. Establishing this information helps guide management by identifying reversible causes and reducing complications associated with defective platelet function.
Choice D rationale
Family and genetic history offer valuable insights into inherited platelet disorders but are less immediately actionable for addressing acute platelet defects. Medications causing or contributing to thrombocytopenia present modifiable factors, prioritizing their identification over hereditary predispositions. Addressing medication-induced platelet dysfunction provides practical management strategies for preventing bleeding complications. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Clients with immune thrombocytopenic purpura (ITP) have a low platelet count, increasing the risk of bleeding. Avoiding rectal and injection medications minimizes the risk of mucosal damage and bleeding complications due to trauma caused by insertion or puncture. This precaution is especially critical as bleeding may not be easily controlled in these clients.
Choice B rationale
An electric razor prevents the risks associated with minor cuts or abrasions that could occur during shaving, which would be difficult to control due to low platelet levels. These injuries could lead to prolonged bleeding or bruising in ITP clients, compromising their safety further.
Choice C rationale
Blood transfusions are generally not indicated as routine interventions for ITP because platelet transfusions may not consistently improve platelet count due to antibody-mediated destruction. Treatment often focuses on medication and careful monitoring rather than transfusion.
Choice D rationale
Constipation should be avoided to reduce strain during bowel movements, which can result in rectal bleeding due to vascular damage in the area. The fragile nature of blood vessels in clients with ITP necessitates such preventive measures to avoid complications.
Choice E rationale
Sulfa-containing medications are known to exacerbate thrombocytopenia in some patients. Avoiding these medications minimizes further platelet depletion, which is vital for managing the condition and preventing severe bleeding episodes.
Correct Answer is D
Explanation
Choice A rationale
Serum electrolyte analysis provides insights into fluid and electrolyte balance but does not specifically diagnose heart failure. Electrolyte changes may occur secondary to heart failure but are not definitive markers for the condition.
Choice B rationale
Complete blood count evaluates for anemia or infection, which may contribute to symptomatology but is not diagnostic for heart failure. Heart failure diagnosis focuses on cardiac-specific markers rather than hematologic parameters.
Choice C rationale
Blood urea nitrogen assesses renal function and reflects perfusion status but lacks specificity for heart failure. Although renal dysfunction may occur in advanced heart failure, BNP measurement is more definitive for cardiac assessment.
Choice D rationale
Brain natriuretic peptide (BNP) is a key diagnostic marker for heart failure. Elevated BNP levels occur due to ventricular stretch and strain associated with fluid overload, a hallmark of heart failure. Normal BNP levels are typically <100 pg/mL, with elevated levels strongly suggesting cardiac dysfunction. .
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