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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

The task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.

Choice B rationale

Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.

Choice C rationale

Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.

Choice D rationale

Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.

A. A client diagnosed with preeclampsia reports epigastric pain and unresolved headache B. A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions C. A client diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes D. A client at 28 weeks of gestation receiving terbutaline reports fine tremors

Correct Answer is A

Explanation

Choice A rationale

A client diagnosed with preeclampsia reporting epigastric pain and unresolved headache is a serious concern. Epigastric pain could indicate severe liver involvement, and a persistent headache could be a sign of progressing neurological involvement, both of which are severe features of preeclampsia. These symptoms suggest the condition may be worsening to eclampsia, a life-threatening complication characterized by the onset of seizure activity or coma in a woman with preeclampsia. Immediate medical attention is necessary to prevent further complications.

Choice B rationale

A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing preterm labor. However, emotional distress and contractions do not necessarily indicate a medical emergency. It’s important to monitor the situation, but it does not need to be immediately reported to the provider.

Choice C rationale

A client diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes are expected findings. Proteinuria is a common sign of preeclampsia, and hyperreflexia can occur due to increased neuromuscular irritability. While these should be monitored, they do not need to be immediately reported to the provider.

Choice D rationale

A client at 28 weeks of gestation receiving terbutaline reporting fine tremors is an expected side effect of the medication. Terbutaline, a beta-adrenergic agonist, can cause tremors by stimulating the nervous system. While it may be uncomfortable for the client, it is not a medical emergency.

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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?

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