Which nursing interventions are appropriate for managing ITP? Select all that apply.

Avoid IM injections

Avoid rectal thermometers

Use a soft toothbrush

Administer aspirin for headache

Monitor stools for occult blood

Answer and Explanation

Correct Answer : A,B,C,E

A. Avoid IM injections: In immune thrombocytopenic purpura (ITP), platelet counts are low, increasing the risk of bleeding and hematoma formation with intramuscular injections. Using alternative routes such as oral or subcutaneous administration when possible reduces trauma to the tissues and prevents uncontrolled bleeding.

B. Avoid rectal thermometers: Rectal instrumentation can cause mucosal trauma and bleeding in patients with thrombocytopenia. Avoiding rectal thermometers helps prevent localized hemorrhage, which can be difficult to control in patients with ITP.

C. Use a soft toothbrush: Patients with ITP are at increased risk of oral mucosal bleeding due to low platelet counts. Using a soft-bristled toothbrush minimizes trauma to the gums during oral hygiene and reduces the risk of gingival bleeding.

D. Administer aspirin for headache: Aspirin has antiplatelet effects and can exacerbate bleeding tendencies in ITP. It should be avoided; alternative analgesics like acetaminophen are preferred. Administering aspirin could precipitate serious hemorrhagic complications.

E. Monitor stools for occult blood: Gastrointestinal bleeding is a potential complication of ITP. Monitoring stools for occult blood allows early detection of internal bleeding, even in the absence of overt symptoms, enabling timely intervention and management of hemorrhagic events.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Decreased B/P, decreased sodium, water retention: This scenario reflects fluid overload with hyponatremia, which is opposite to the pathophysiology of diabetes insipidus. In DI, the kidneys fail to concentrate urine, leading to water loss rather than retention, so sodium levels typically rise rather than decrease.

B. Decreased B/P, increased sodium, polyuria: Diabetes insipidus is characterized by a deficiency of antidiuretic hormone (central DI) or renal insensitivity to ADH (nephrogenic DI). This leads to excessive free water loss, causing polyuria and dehydration. Dehydration results in hypotension and hypernatremia due to reduced plasma volume and concentration of serum sodium.

C. Increased B/P, increased sodium, polydipsia: While polydipsia is a hallmark of DI, blood pressure usually decreases rather than increases due to volume depletion. Elevated blood pressure is not consistent with the hypovolemic state caused by excessive fluid loss in DI.

D. Increased B/P, decreased sodium, oliguria: Oliguria and hyponatremia are not features of diabetes insipidus. Oliguria suggests reduced urine output, whereas DI presents with copious urine output. Hyponatremia results from water retention, not loss, and does not reflect the hypernatremia seen in DI.

A. Loss of bowel control B. Sharp thoracic back pain C. Inability to move arms D. Progressive muscle weakness in legs E. Paresthesia in lower extremities

Correct Answer is ["A","B","D","E"]

Explanation

A. Loss of bowel control: Loss of bowel or bladder control is a late sign of spinal cord compression. Compression of sacral nerve roots impairs autonomic function, making this a critical symptom to assess and report immediately.

B. Sharp thoracic back pain: Localized, severe, or sharp back pain, especially in the thoracic region, is often the earliest symptom of spinal cord compression. It may worsen with movement or coughing and signals pressure on vertebral or spinal structures.

C. Inability to move arms: Arm paralysis occurs only if cervical spinal cord levels are affected. In metastatic cancer, compression is most commonly thoracic or lumbar, so upper extremity motor loss is less typical and not a consistent finding unless the lesion is cervical.

D. Progressive muscle weakness in legs: Weakness in the lower extremities is a hallmark early manifestation of thoracic or lumbar spinal cord compression. It typically progresses gradually, reflecting motor pathway involvement.

E. Paresthesia in lower extremities: Sensory changes, such as numbness, tingling, or burning sensations in the legs, occur as the spinal cord or nerve roots are compressed. Early recognition helps prevent permanent neurologic deficits.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which nursing interventions are appropriate for managing ITP? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse distinguishes that a patient may experience which signs and symptoms related to diabetes insipidus (DI)?

Correct Answer is B

Explanation

Which assessment findings are consistent with spinal cord compression in a patient with metastatic cancer? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a patient 4 hours after a thyroidectomy. Which assessment finding requires immediate intervention?

A patient is being treated for shock. The nurse knows that shock is a clinical syndrome characterized by which physiologic state?

A patient is admitted with possible syndrome of inappropriate anti-diuretic hormone (SIADH). Which information obtained by the nurse is most important to communicate rapidly to the health care provider?

Four victims of an automobile accident are brought by the ambulance to the emergency department. Based on the principles of triage, the nurse determines that which patient has the highest priority for treatment?

After receiving change-of-shift report on the burn unit, which patient would the nurse assess first?

A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic finding supports this diagnosis?

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?