A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:
Fatigue
Side effects of immunosuppressants
Thrombocytopenia
Infection
The Correct Answer is C
Choice A reason: Fatigue is a common symptom of ITP but is not the primary concern for monitoring, as it does not directly indicate the severity of the condition.
Choice B reason: While monitoring for side effects of immunosuppressants is important, it is not the priority concern. The primary issue in ITP is the low platelet count, which poses a risk of bleeding.
Choice C reason: Thrombocytopenia, or low platelet count, is the hallmark of ITP and the main concern for monitoring, as it increases the risk of bleeding and bruising.
Choice D reason: Infection is a risk due to the potential use of immunosuppressants in treatment; however, the immediate concern in ITP management is the platelet count and associated bleeding risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The normal range for serum creatinine is indeed 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. Serum creatinine is a waste product from the normal breakdown of muscle tissue. As kidneys become impaired for any reason, the serum creatinine level rises due to poor clearance by the kidneys.
Choice B reason: A GFR below 60 mL/min/1.73 m for three months or more is one of the criteria for the diagnosis of chronic kidney disease. GFR is a measure of how well the kidneys filter blood, and a lower GFR indicates poorer kidney function.
Choice C reason: Blood urea nitrogen (BUN) levels should indeed be between 7 and 20 mg/dL. BUN measures the amount of nitrogen in your blood that comes from the waste product urea. Urea is made when protein is broken down in your body. BUN levels can rise with the level of protein in your diet and your kidney function[^10^].
Choice D reason: An increase in serum potassium can indicate hyperkalemia, which may be a sign of acute kidney injury. Potassium is a critical electrolyte, and its levels are tightly regulated by the kidneys. High levels can lead to dangerous heart rhythms.
Correct Answer is C
Explanation
Choice A reason: Weighing the client daily is important for monitoring fluid balance but is not the most immediate action to prevent an Addisonian crisis.
Choice B reason: Restricting fluid intake is not appropriate for a client at risk for Addisonian crisis, as they may require increased fluids to prevent dehydration.
Choice C reason: This is the correct action. Clients with Addison's disease require corticosteroids to replace the hormones that their adrenal glands are not producing.
Choice D reason: Providing a low carbohydrate diet is not relevant to the prevention of an Addisonian crisis.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
