The nurse is planning care for a client diagnosed with immune thrombocytopenia. Which nursing intervention should be included in the plan of care?

Teaching coughing and deep breathing techniques to help prevent infection

Giving aspirin, as ordered, to control body temperature

Administering platelets, as ordered, to maintain an adequate platelet count

Administering stool softeners, as ordered, to prevent straining during defecation

Answer and Explanation

The Correct Answer is C

Reasoning:

Choice A reason: Teaching coughing and deep breathing techniques prevents respiratory infections but is not the primary intervention for immune thrombocytopenia (ITP). ITP involves autoimmune platelet destruction, increasing bleeding risk. While infection prevention is important, maintaining platelet counts through transfusion is more critical to prevent hemorrhage in ITP.

Choice B reason: Giving aspirin to control temperature is contraindicated in ITP, as aspirin inhibits platelet function, worsening bleeding risk in clients with low platelet counts. Fever management should use alternative antipyretics like acetaminophen, making aspirin administration inappropriate and potentially harmful in this condition.

Choice C reason: Administering platelets, as ordered, is a key intervention in immune thrombocytopenia when bleeding risk is high. ITP causes autoimmune destruction of platelets, leading to thrombocytopenia. Platelet transfusions restore counts, reducing the risk of spontaneous bleeding, such as intracranial or gastrointestinal hemorrhage, a critical concern in severe cases.

Choice D reason: Administering stool softeners prevents straining, which could cause bleeding in ITP due to low platelets. While useful, it is secondary to platelet transfusion, which directly addresses the primary issue of thrombocytopenia and bleeding risk, making it less urgent than restoring platelet counts.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Confusion may occur in SIADH due to hyponatremia-induced cerebral edema, but diarrhea is not a typical sign of fluid overload. Diarrhea causes fluid loss, which is opposite to the water retention seen in SIADH, making this combination less indicative of fluid overload compared to cardiovascular or respiratory signs.

Choice B reason: Hypertension may occur in SIADH due to fluid overload, but weight gain without edema is less specific. SIADH often causes subtle fluid retention without overt edema, but weight gain alone does not fully indicate fluid overload, as it lacks the respiratory or cardiovascular specificity of dyspnea and hypertension.

Choice C reason: Pulmonary congestion may indicate fluid overload in SIADH, as excess water can lead to pulmonary edema. However, muscle cramps are more related to hyponatremia than fluid overload itself. This combination is less precise than dyspnea and hypertension for identifying fluid overload in this context.

Choice D reason: Dyspnea and hypertension are key indicators of fluid overload in SIADH. Excessive ADH causes water retention, increasing blood volume, which raises blood pressure. Fluid accumulation in the lungs can cause dyspnea, reflecting pulmonary edema, a serious complication of fluid overload in SIADH, making this the most accurate finding.

A. Third-spacing and hyperthermia B. Bradycardia and hypertension C. Tachycardia and agitation D. Respiratory distress and projectile vomiting

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Third-spacing and hyperthermia are not typical of autonomic dysreflexia, a condition in spinal cord injury causing sympathetic overactivity. Third-spacing occurs in fluid shifts like edema, and hyperthermia suggests infection, not the autonomic response to stimuli like bladder distension triggering dysreflexia.

Choice B reason: Autonomic dysreflexia, common in spinal cord injuries above T6, causes bradycardia and hypertension. Noxious stimuli (e.g., bladder distension) trigger sympathetic overactivity, raising blood pressure, while baroreceptors stimulate vagal response, slowing heart rate, making these classic manifestations of this life-threatening condition.

Choice C reason: Tachycardia and agitation may occur in other conditions but are not primary in autonomic dysreflexia. Hypertension triggers a compensatory bradycardia, not tachycardia, and while agitation may accompany distress, the hallmark is the cardiovascular response, making this less accurate.

Choice D reason: Respiratory distress and projectile vomiting are not primary manifestations of autonomic dysreflexia. While severe hypertension may cause nausea, the classic signs are bradycardia and hypertension due to sympathetic overactivity from stimuli below the spinal injury, not respiratory or vomiting issues.

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The nurse is planning care for a client diagnosed with immune thrombocytopenia. Which nursing intervention should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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