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 B

Explanation

Reasoning:

Choice A reason: A chest x-ray evaluates cardiopulmonary conditions but is not the initial test for CVA. It may be used to rule out secondary issues, but brain imaging is critical to differentiate ischemic from hemorrhagic stroke, guiding treatment like thrombolytics, making chest x-ray less urgent.

Choice B reason: A brain CT scan or MRI is the initial diagnostic evaluation for CVA to distinguish ischemic from hemorrhagic stroke. CT is faster and widely used to rule out hemorrhage before thrombolytic therapy, ensuring safe treatment. MRI provides detailed imaging but is less common in emergencies due to time constraints.

Choice C reason: Prothrombin level assesses coagulation but is not the initial test for CVA. It is relevant for patients on anticoagulants or before thrombolytics, but brain imaging takes precedence to confirm stroke type and guide urgent treatment, making coagulation tests secondary.

Choice D reason: Lumbar puncture is not routine for CVA diagnosis, as it risks brain herniation in cases of increased intracranial pressure. It may be used for subarachnoid hemorrhage if imaging is inconclusive, but brain CT or MRI is the primary and safer initial evaluation.

A. Above-normal urine osmolality level, below-normal serum osmolality level B. Above-normal urine and serum osmolality levels C. Below-normal urine osmolality level, above-normal serum osmolality level D. Below-normal urine and serum osmolality levels

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Above-normal urine osmolality and below-normal serum osmolality are not consistent with diabetes insipidus. High urine osmolality suggests concentrated urine, typical in syndrome of inappropriate antidiuretic hormone (SIADH), where ADH is excessive. Low serum osmolality also aligns with SIADH due to water retention, not the water loss seen in diabetes insipidus.

Choice B reason: Above-normal urine and serum osmolality levels do not reflect diabetes insipidus. High urine osmolality indicates concentrated urine, which contradicts the dilute urine output of diabetes insipidus. High serum osmolality could occur with dehydration, but the combination with high urine osmolality suggests another condition, not ADH deficiency.

Choice C reason: Below-normal urine osmolality and above-normal serum osmolality are classic findings in diabetes insipidus. Arginine vasopressin (ADH) deficiency impairs water reabsorption, leading to dilute urine (low osmolality). The resulting water loss increases serum osmolality as the body becomes dehydrated, supporting the diagnosis of diabetes insipidus.

Choice D reason: Below-normal urine and serum osmolality levels are inconsistent with diabetes insipidus. Low urine osmolality occurs due to ADH deficiency, but low serum osmolality suggests water retention, as in SIADH. Diabetes insipidus causes dehydration, elevating serum osmolality, not lowering it, making this combination unlikely in this condition.

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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?

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