A nurse is developing a care plan for a patient who has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which of the following symptoms is most important for the nurse to monitor?
Elevated WBC count.
Fever.
Ecchymosis.
Fatigue.
The Correct Answer is C
Choice A rationale
While an elevated WBC count can indicate an infection, it is not the most important symptom to monitor in a patient with idiopathic thrombocytopenic purpura (ITP). ITP is primarily a platelet disorder, and while infection can trigger or exacerbate the condition, an elevated WBC count is not a direct symptom of ITP78.
Choice B rationale
Fever can be a sign of infection, which can trigger or exacerbate ITP. However, it is not the most important symptom to monitor in a patient with ITP78.
Choice C rationale
Ecchymosis, or bruising, is a key symptom of ITP. Because ITP involves a decrease in platelets, which are necessary for clotting, patients with this condition are prone to bruising and bleeding. Therefore, monitoring for ecchymosis is crucial.
Choice D rationale
Fatigue can be a symptom of ITP, but it is not the most important symptom to monitor. While fatigue can impact a patient’s quality of life, it does not directly indicate the severity of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Fetal motion is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its movements16.
Choice B rationale
Fetal neck translucency is not evaluated during a biophysical profile. It is usually measured during an ultrasound examination in the first trimester of pregnancy as a part of screening for chromosomal abnormalities.
Choice C rationale
Fetal gender is not evaluated during a biophysical profile. The focus of a biophysical profile is on the baby’s health, not its gender16.
Choice D rationale
Fetal breathing is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its breathing movements16.
Choice E rationale
Amniotic fluid volume is indeed evaluated during a biophysical profile. It assesses the health of the baby by measuring the amount of amniotic fluid surrounding the fetus in the uterus16.
Correct Answer is B
Explanation
Choice A rationale
Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.
Choice B rationale
Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.
Choice C rationale
While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.
Choice D rationale
Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.
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