Which sign would the nurse expect to assess in the patient diagnosed with idiopathic thrombocytopenic purpura (ITP)?

Capillary refill less than three (3) seconds

Pulse oximeter reading of 95%

An enlarged spleen

Petechiae on the anterior chest, arms, and neck

Answer and Explanation

The Correct Answer is D

A. Capillary refill less than three (3) seconds: A normal capillary refill indicates adequate peripheral perfusion and is not a typical finding associated with idiopathic thrombocytopenic purpura (ITP), which primarily affects platelet count and bleeding tendencies rather than perfusion.

B. Pulse oximeter reading of 95%: Oxygen saturation reflects respiratory function and is generally unaffected in ITP. This reading does not correlate with the hematologic manifestations of the disorder.

C. An enlarged spleen: Splenomegaly is more characteristic of secondary causes of thrombocytopenia, such as certain infections or hematologic malignancies. In classic ITP, the spleen is usually normal in size.

D. Petechiae on the anterior chest, arms, and neck: Petechiae are small, pinpoint hemorrhages resulting from platelet deficiency and are a hallmark sign of ITP. They appear on areas prone to pressure or trauma and indicate the patient’s increased risk for bleeding due to thrombocytopenia.

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Correct Answer is B

Explanation

A. Initiate high-dose barbiturate therapy: High-dose barbiturates are sometimes used to reduce cerebral metabolic demand in cases of refractory increased intracranial pressure, but they do not treat the underlying cause of an epidural hematoma. This intervention is not the initial priority.

B. Prepare patient for immediate craniotomy: Epidural hematomas are often caused by arterial bleeding, leading to rapidly increasing intracranial pressure and potential brain herniation. Surgical evacuation via craniotomy is the definitive treatment and must be performed emergently to prevent permanent neurologic damage or death. Prompt preparation for surgery is the priority.

C. Type and cross-match for blood transfusion: While blood may be needed in some trauma cases, transfusion is not the primary intervention for an epidural hematoma. The immediate focus is surgical evacuation to relieve pressure on the brain.

D. Administer IV furosemide: Furosemide is a diuretic that can be used to manage fluid overload or reduce ICP in certain situations, but it does not address the acute mass effect of an epidural hematoma. It is not indicated as an emergent treatment in this context.

A. "An EEG can be used alone to determine if brain activity is still present in patients who are unresponsive." B. "An EEG is not needed to determine brain death as clinical signs are sufficient." C. "The EEG will confirm brain death when no electrical activity is present in the brain." D. "An EEG may show normal brain activity in patients who are close to brain death."

Correct Answer is C

Explanation

A. "An EEG can be used alone to determine if brain activity is still present in patients who are unresponsive.": EEG cannot be used in isolation to declare brain death because it may be affected by medications, metabolic disturbances, or hypothermia, and clinical assessment is required for a comprehensive evaluation.

B. "An EEG is not needed to determine brain death as clinical signs are sufficient.": While clinical criteria are central to brain death determination, EEG may be used as an ancillary test in certain situations, such as when confounding factors prevent full clinical assessment, to provide objective confirmation of electrical inactivity.

C. "The EEG will confirm brain death when no electrical activity is present in the brain.": EEG records cortical electrical activity, and the absence of detectable activity (electrocerebral silence) supports the diagnosis of brain death when combined with a complete clinical evaluation. This makes it a reliable confirmatory tool in specific cases.

D. "An EEG may show normal brain activity in patients who are close to brain death.": Patients nearing brain death generally exhibit severely diminished or absent cortical activity. Normal EEG findings would indicate preserved brain function and are inconsistent with imminent brain death.

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Which sign would the nurse expect to assess in the patient diagnosed with idiopathic thrombocytopenic purpura (ITP)?

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Explanation

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