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 C
Explanation
Choice A reason: Dullness on percussion typically indicates increased lung density, such as in conditions where lung tissue is consolidated or fluid-filled. This sound is heard in cases of:Pneumonia (due to alveolar consolidation)Pleural effusion (fluid in the pleural space)Lung tumors (solid masses in lung tissue) Since chronic bronchitis is primarily an airway disease characterized by inflammation and mucus production rather than lung consolidation or fluid accumulation, dullness is not an expected finding..
Choice B reason: Tympany is usually heard over air-filled structures and is not a percussion sound typically associated with chronic bronchitis.
Choice C reason:
Resonance is the normal percussion sound heard over healthy lung fields, indicating air-filled alveoli. Since chronic bronchitis does not cause significant air trapping or lung consolidation, percussion remains resonant rather than hyperresonant (as in emphysema) or dull (as in pneumonia). Thus, resonance is the expected finding in chronic bronchitis because the lung parenchyma remains relatively unaffected despite the chronic airway inflammation.
Choice D reason: Flatness is heard over very dense tissue, such as muscle or bone, and is not characteristic of chronic bronchitis.
Correct Answer is D
Explanation
Choice A reason: The prone position is not suitable for abdominal paracentesis as it does not allow access to the abdominal cavity.
Choice B reason: The lateral position is also not suitable as it can cause the fluid to shift, making it difficult to remove.
Choice C reason: While the supine position is commonly used for many medical procedures, it is not the best choice for abdominal paracentesis due to the distribution of fluid.
Choice D reason: The upright position is preferred because it allows the fluid to pool at the lowest point of the abdominal cavity, facilitating its removal.
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