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 D

Explanation

Choice A reason: This choice is incorrect. A stroke involving the right cerebral hemisphere typically affects the left side of the body and can cause problems with spatial and perceptual abilities, not necessarily with language or discrimination of words and letters, which are more commonly associated with left hemisphere strokes⁸.

Choice B reason: Motor retardation is not specific to right hemisphere strokes. While right hemisphere strokes can cause weakness on the left side of the body, the term 'motor retardation' is not commonly used to describe this symptom⁸.

Choice C reason: This choice is incorrect because deficits in the right visual field would suggest a problem with the left cerebral hemisphere, not the right. A right hemisphere stroke typically causes problems with the left visual field⁸.

Choice D reason: This is the correct choice. Individuals with right hemisphere strokes may exhibit poor impulse control, as the right hemisphere is involved in judgment and behavior regulation⁸.

A. Blow nose gently. B. Lubricate lips with water-soluble ointment. C. Use a straightedge razor to shave. D. Brush teeth with a soft toothbrush. E. Limit fruit consumption.

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Blowing the nose gently is advised to prevent nosebleeds, which can be a risk due to thrombocytopenia.

Choice B reason: Lubricating lips with water-soluble ointment can prevent cracking and bleeding, which is important for a patient with thrombocytopenia.

Choice C reason: Using a straightedge razor is not recommended because it can increase the risk of cuts and bleeding. An electric razor would be safer.

Choice D reason: Brushing teeth with a soft toothbrush is recommended to prevent gum bleeding due to the low platelet count associated with thrombocytopenia.

Choice E reason: Limiting fruit consumption is not necessary for thrombocytopenia unless the patient has a specific condition that requires dietary restrictions.

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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 caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is D

Explanation

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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