A client with thrombocytopenia presents with petechiae, pallor, and weakness.
Which intervention should the nurse implement to address the client's symptoms?
Apply pressure to any bleeding site and elevate the affected area.
Administer plasma exchange therapy.
Monitor renal function and fluid balance.
Prepare the client for immunosuppressant therapy.
The Correct Answer is A
Choice B rationale:
Administer plasma exchange therapy Administering plasma exchange therapy may be indicated in some cases of thrombocytopenia, but it is not the initial intervention when a client presents with petechiae, pallor, and weakness.
The primary concern in this situation is addressing active bleeding, which is best managed by applying pressure to bleeding sites and elevating the affected area.
Choice C rationale:
Monitor renal function and fluid balance While monitoring renal function and fluid balance is important in the overall care of a client with thrombocytopenia, it is not the immediate intervention when the client presents with symptoms of bleeding and weakness.
The priority is to stop the bleeding by applying pressure and elevating the affected area.
Choice D rationale:
Prepare the client for immunosuppressant therapy Immunosuppressant therapy may be considered as a treatment option for certain types of thrombocytopenia, but it is not the initial intervention when the client has active bleeding and weakness.
The immediate focus should be on bleeding control and symptom management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Monitoring the patient's neurological status While monitoring neurological status is important in patient care, it is not the immediate priority when a patient with thrombocytopenia reports hematochezia (bloody stools), fatigue, and abdominal pain.
Checking vital signs helps assess the patient's overall stability and guides immediate interventions.
Choice C rationale:
Administering corticosteroids Administering corticosteroids may be a treatment option for certain types of thrombocytopenia, but it is not the initial priority in the assessment of a patient presenting with hematochezia, fatigue, and abdominal pain.
First, the nurse needs to assess the patient's condition and vital signs to determine the severity of the situation.
Choice D rationale:
Preparing the patient for a splenectomy Preparing a patient for a splenectomy is a significant intervention and should not be the initial priority in this case.
It may be considered as a treatment option in some cases of thrombocytopenia, but it should not take precedence over assessing the patient's vital signs and overall condition.
Correct Answer is B
Explanation
Choice A rationale:
Encourage the patient to consume NSAIDs for pain relief.
Encouraging the use of NSAIDs for pain relief is not appropriate for patients with thrombocytopenia.
NSAIDs can further increase the risk of bleeding due to their antiplatelet effects.
Therefore, it is crucial to educate patients to avoid NSAIDs.
Choice B rationale:
Teach the patient to avoid alcohol and aspirin.
This is a crucial part of patient education for those with thrombocytopenia.
Alcohol and aspirin can both increase the risk of bleeding, so advising patients to avoid them is essential to minimize bleeding risks.
Choice C rationale:
Suggest regular injections to stimulate platelet production.
While there are treatments available to stimulate platelet production, they are typically prescribed by a healthcare provider based on the patient's specific diagnosis and medical needs.
Suggesting regular injections without medical guidance is not appropriate.
Choice D rationale:
Advise the patient to skip monitoring platelet counts.
Regular monitoring of platelet counts is essential for patients with thrombocytopenia to assess the effectiveness of treatment and identify any potential complications.
Advising the patient to skip monitoring is not appropriate and may lead to undetected issues.
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