With which term will the nurse document the finding after noting multiple 1-mm red macules when assessing the skin of a patient with leukemia and thrombocytopenia?
Purpura.
Bruising.
Petechiae.
Ecchymosis.
The Correct Answer is C
Choice A rationale:
Purpura refers to purple or red discolorations on the skin caused by bleeding underneath the skin. It is larger than petechiae and ecchymosis and could be a sign of a more serious underlying condition. Petechiae are small, red or purple dots that appear on the skin due to minor bleeding from broken capillaries. In the context of leukemia and thrombocytopenia (low platelet count), petechiae are common due to impaired clotting mechanisms.
Choice B rationale:
Bruising occurs due to damage to blood vessels underneath the skin, resulting in the leakage of blood into the surrounding tissues. Bruises are typically larger than petechiae and can occur with various conditions, including trauma. In this case, the small 1-mm red macules are more indicative of petechiae.
Choice D rationale:
Ecchymosis refers to a larger area of subcutaneous bleeding or bruising. It is larger than both petechiae and purpura and often results from more significant trauma or bleeding disorders. The description of multiple 1-mm red macules is characteristic of petechiae rather than ecchymosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Palpating lymph nodes for swelling is not directly related to thrombocytopenia. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to easy bruising and bleeding. Checking lymph nodes is more relevant in assessing for infection or malignancy.
Choice B rationale:
Checking temperature for elevation is important for assessing infection, which could be a cause of thrombocytopenia. However, in this context, inspecting the skin for bruising or petechiae is more specific to thrombocytopenia. Petechiae are small, red or purple dots that appear on the skin when platelet count is low.
Choice D rationale:
Examining oral mucosa for ulceration is essential in the assessment of conditions like oral cancer or infection. While thrombocytopenia could lead to bleeding in the oral mucosa, it is not the most specific or immediate concern in a patient with known thrombocytopenia.
Correct Answer is C
Explanation
Choice A rationale:
The sodium level is within the normal range, but the potassium level is slightly elevated. This does not support the rationale for changing the IV prescription to a lower potassium concentration.
Choice B rationale:
The sodium level is slightly elevated, and the potassium level is within the normal range. This does not support the rationale for changing the IV prescription to a lower potassium concentration.
Choice C rationale:
Sodium level of 135 mEq/L, potassium level of 3.6 mEq/L is the correct answer. In this option, both sodium and potassium levels are within normal ranges. Changing the IV prescription to DSNS with 20 mEq KCl/L ensures that the patient receives adequate hydration (from the dextrose and normal saline) without causing hyperkalemia.
Choice D rationale:
The sodium level is slightly elevated, and the potassium level is within the normal range. This does not support the rationale for changing the IV prescription to a lower potassium concentration.
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