A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?

Petechiae on the oral mucosa.

Hemoglobin of 14 g/dL.

Bleeding of the gums after oral care.

Pain and swelling in one leg.

Answer and Explanation

The Correct Answer is D

A.   Petechiae are tiny, pinpoint, red or purple spots on the skin or mucous membranes, caused by bleeding under the skin. While petechiae can indicate bleeding, they are not specific to HIT and can occur due to various reasons, including low platelet count or coagulation disorders. They do not necessarily indicate thrombotic complications associated with HIT.
B.   This hemoglobin level is within the normal range for adults and does not directly correlate with HIT. However, it is important to monitor hemoglobin levels in patients with HIT due to the risk of bleeding and thrombosis.
C.   Bleeding gums can occur due to various reasons, including gum disease or thrombocytopenia (low platelet count). In HIT, the concern is not just bleeding but also the paradoxical risk of thrombosis despite low platelet counts. Bleeding from mucosal surfaces can indicate underlying thrombocytopenia but does not specifically highlight the thrombotic risk of HIT.
D.   This symptom is concerning for deep vein thrombosis (DVT), which is a thrombotic complication associated with HIT. HIT predisposes patients to thrombosis due to the formation of antibodies against

platelet factor 4/heparin complexes, leading to platelet activation and clot formation. DVT is a serious complication that requires immediate intervention to prevent pulmonary embolism (PE).

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Correct Answer is A

Explanation

A. By surrounding themselves with familiar items, such as photos, favorite objects, or comforting decor from their previous home, the resident can feel more at ease and connected to their past. This approach helps in creating a more homelike atmosphere and reducing feelings of disorientation and stress associated with the move.
B. Isolating the resident and encouraging avoidance of social interactions can exacerbate feelings of loneliness, isolation, and anxiety. Avoiding social interactions may prolong feelings of stress and hinder adaptation to the new living situation.
C. While it's important to manage the frequency and timing of visits to ensure the resident is not overwhelmed, outright restricting visitation hours can be counterproductive. Restricting visitation could increase feelings of isolation and loneliness, which are already common in new residents of long-term care facilities.
D. Using sedative medications should be reserved for situations where non-pharmacological interventions have been unsuccessful and the resident's anxiety or distress is severe and persistent. Sedatives can have side effects, especially in older adults, and should not be the first-line approach for managing relocation stress syndrome.

A. Assess pedal pulses B. Assess nutritional status C. Assess urine output D. Assess liver function

Correct Answer is C

Explanation

A. While assessing pedal pulses is important for circulation and can indicate peripheral vascular status, it is not the highest priority compared to assessing renal function in a client with TTP.
B. Nutritional status is important for overall health and recovery but is not immediately critical compared to assessing for acute complications such as kidney damage in TTP.
C. TTP can lead to kidney damage due to the formation of clots in the small blood vessels of the kidneys. This can result in decreased urine output or even acute kidney injury (AKI). Monitoring urine output is crucial to assess renal function and detect early signs of kidney involvement.
D. TTP primarily affects the kidneys and blood coagulation system, leading to hemolysis and thrombocytopenia. Liver function is not typically a primary concern in TTP unless there are concurrent issues or complications.

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A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?

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A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?