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: Tennis involves abrupt lateral movements and may not be suitable for someone with low back pain, as it can exacerbate the condition.
Choice B reason: Swimming is a low impact exercise that can help strengthen the back muscles without putting additional stress on the spine, making it an ideal choice for individuals with low back pain.
Choice C reason: The option "Custom: NUR 224G Sec 2 Blandon Final" does not refer to a specific exercise and seems to be an error or unrelated text.
Choice D reason: Rowing can be strenuous on the lower back due to the repetitive motion and the need for strong core engagement, which might not be recommended for acute low back pain.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. Partial compensation would typically involve a change in PaCO2 to counterbalance the elevated bicarbonate, which is not observed here.
Choice B reason: This choice is incorrect. Respiratory acidosis is characterized by a low pH and an elevated PaCO2, which is not consistent with the given values.
Choice C reason: This choice is incorrect. Respiratory alkalosis would present with a low PaCO2 due to hyperventilation, which is not the case here.
Choice D reason: This is the correct choice. The elevated pH and HCO3 with a normal PaCO2 indicate metabolic alkalosis without respiratory compensation. Persistent vomiting can lead to loss of stomach acid, which causes metabolic alkalosis.
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