The nurse is planning care for a client with immune thrombocytopenic purpura (ITP). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Teach the client to avoid rectal and injection medications.

Teach the client about using an electric razor.

Prepare the client for a prescribed blood transfusion.

Teach the client to avoid constipation.

Explain the importance of avoiding taking sulfa-containing medications.

Answer and Explanation

Correct Answer : A,B,D,E

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.

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Correct Answer is A

Explanation

Choice A rationale

Corticosteroids are the mainstay of treatment for thrombocytopenia, particularly immune-mediated types like ITP. They work by suppressing immune-mediated platelet destruction, thereby increasing platelet counts and improving symptoms effectively.

Choice B rationale

Diphenhydramine, an antihistamine, may be used for allergic reactions but has no role in treating thrombocytopenia. It does not address immune-mediated mechanisms or platelet destruction directly.

Choice C rationale

Desmopressin (DDAVP) increases von Willebrand factor and Factor VIII activity, making it appropriate for certain clotting disorders but irrelevant for thrombocytopenia, as it does not restore platelet numbers or function.

Choice D rationale

Hydrochlorothiazide, a diuretic, is used for hypertension or fluid management but has no therapeutic effect on platelet counts or immune-mediated mechanisms in thrombocytopenia. Its use is unrelated to the described condition. .

A. Over-the-counter Sudafed should not be taken while I am taking this medication. B. I will stop taking the medication if I have any signs or symptoms of infection. C. I will not combine this medication with any type of antidepressant medications. D. Retention of urine can occur while taking the medication and should be reported.

Correct Answer is A

Explanation

Choice A rationale

Over-the-counter Sudafed contains pseudoephedrine, which can cause urinary retention by stimulating alpha-adrenergic receptors, exacerbating symptoms treated by oxybutynin. Avoiding this combination reduces the risk of adverse effects, indicating correct client understanding.

Choice B rationale

Stopping the medication due to signs of infection is incorrect. Oxybutynin addresses bladder muscle control and is not associated with infection management. Reporting adverse effects is required, but discontinuation must follow medical advice.

Choice C rationale

Antidepressants like tricyclics have anticholinergic effects similar to oxybutynin, potentially increasing adverse effects. However, abrupt contraindication is incorrect unless specified by a healthcare provider, indicating a misunderstanding.

Choice D rationale

Urinary retention is a known side effect of oxybutynin. Reporting symptoms is correct, but this statement lacks broader understanding of the medication’s use and side effect profile. .

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The nurse is planning care for a client with immune thrombocytopenic purpura (ITP). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has thrombocytopenia.Which of the following will the nurse administer for this disorder?

Correct Answer is A

Explanation

The nurse has taught a client with urinary incontinence about taking prescribed oxybutynin chloride.Which of the following statements by the client would indicate a correct understanding of the teaching?

Correct Answer is A

Explanation

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