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 C

Explanation

Choice A reason: This choice is incorrect. Painless, raised purple nodules on the hard palate are not typically indicative of squamous cell carcinoma.

Choice B reason: This choice is incorrect. A small macule with a yellow-brown scale does not describe squamous cell carcinoma, which often presents as a firm nodule with a scaly crust.

Choice C reason: This is the correct choice. Squamous cell carcinoma can present as a firm nodule with a hard, scaly crust on the skin.

Choice D reason: Yellow white patches of growth on the tongue are more indicative of conditions such as oral leukoplakia, not squamous cell carcinoma.

A. Dehydration B. Burns C. Shivering D. Seizures

Correct Answer is C

Explanation

Choice A reason: Dehydration is a concern with fever, but it is not a direct complication of hypothermia blanket therapy. It is important to ensure adequate hydration, but the primary concern with hypothermia therapy is not dehydration.

Choice B reason: Burns could occur if the hypothermia blanket malfunctions or is used improperly. However, modern devices have safety features to prevent burns, making this a less likely complication.

Choice C reason: Shivering is a natural response to cooling and can occur as the body attempts to generate heat in response to the lowered temperature from the hypothermia blanket. It can be counterproductive to the therapy and may need to be controlled with medications.

Choice D reason: Seizures are not a typical complication of hypothermia blanket therapy. While meningitis can cause seizures due to inflammation of the brain, the hypothermia blanket itself does not induce seizures.

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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 performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

Correct Answer is C

Explanation

A nurse is caring for a client who has meningitis and a temperature of 39.7°C (103.5°F). The client is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must be carefully observed for which of the following complications?

Correct Answer is C

Explanation

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