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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: A blood pressure reading of 124/79 mm Hg is considered elevated. The normal range for blood pressure is less than 120/80 mm Hg. Elevated blood pressure is when readings consistently range from 120129 systolic and less than 80 mm Hg diastolic.

Choice B reason: Stage 1 hypertension is defined by a systolic blood pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg. The client's blood pressure does not fall into this category.

Choice C reason: Stage 2 hypertension is characterized by a systolic blood pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. The client's blood pressure is below these levels.

Choice D reason: A normal blood pressure reading is typically below 120/80 mm Hg. Although the client's diastolic pressure is within the normal range, the systolic pressure is above normal, thus it does not qualify as a normal blood pressure reading.

A. Ménière's disease B. Mastoiditis C. Perforated tympanic membrane D. Acoustic neuroma

Correct Answer is C

Explanation

Choice A reason: Ménière's disease typically presents with vertigo, tinnitus, and hearing loss, not sudden resolution of ear pain with otorrhea.

Choice B reason: Mastoiditis may cause ear pain and drainage, but it is usually accompanied by fever and tenderness over the mastoid bone, not sudden pain resolution.

Choice C reason: A perforated tympanic membrane can lead to the sudden resolution of ear pain followed by drainage, as the pressure causing the pain is relieved when the eardrum ruptures.

Choice D reason: Acoustic neuroma typically presents with progressive hearing loss and tinnitus, not ear pain or otorrhea.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories?

Correct Answer is A

Explanation

A nurse is assessing a client who reports ear pain for the past three days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

Correct Answer is C

Explanation

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