A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?

A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium (Tensilon) test.

A client with Bell's palsy who has an order for prednisone and acyclovir.

A client with Parkinson's disease who has hypokinetic dysarthria and a lack of facial expressions.

A client with multiple sclerosis who has bladder flaccidity and is retaining urine.

Answer and Explanation

The Correct Answer is A

A.   A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium test is likely experiencing a myasthenic crisis, which is a life-threatening condition that requires immediate attention. This client would be the priority because they may require rapid intervention to maintain airway and breathing.
B.   Bell's palsy is characterized by sudden onset of facial paralysis due to inflammation of the facial nerve. While Bell's palsy can be distressing for the client, it does not typically require urgent intervention unless there are complications such as corneal abrasion due to inability to close the eye.
C.   Parkinson's disease is a chronic neurodegenerative disorder characterized by motor symptoms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. While this client requires ongoing assessment and care, the symptoms described do not typically indicate an acute or urgent need for intervention.
D.   A client with multiple sclerosis who has bladder flaccidity and is retaining urine needs assessment and intervention to prevent complications such as urinary tract infections or renal damage. However, this is not as immediately life-threatening as a myasthenic crisis.

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Correct Answer is D

Explanation

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).

A. Platelet factor 4 (PF4) bound with heparin forming a PF4-heparin complex. B. Abnormally long von Willebrand factor. C. A deficiency of the enzyme ADAMTS13. D. Platelets which are coated with antibodies.

Correct Answer is D

Explanation

A. This option describes a phenomenon seen in heparin-induced thrombocytopenia (HIT), not in immune thrombocytopenic purpura (ITP). In HIT, antibodies against the PF4-heparin complex can cause platelet activation and aggregation, leading to thrombocytopenia. However, this is not characteristic of ITP.
B. Abnormally long von Willebrand factor is seen in von Willebrand disease (VWD), not in ITP. VWD is a bleeding disorder caused by deficiency or dysfunction of von Willebrand factor, which plays a key role in platelet adhesion and aggregation. It is not typically associated with ITP.

C. ADAMTS13 deficiency is characteristic of thrombotic thrombocytopenic purpura (TTP), not ITP. TTP is a rare blood disorder where small blood clots form in blood vessels throughout the body, leading to thrombocytopenia (low platelet count) and other complications. It is distinct from ITP.
D. In immune thrombocytopenic purpura (ITP), the immune system mistakenly attacks and destroys platelets, leading to a low platelet count. Antibodies, particularly anti-platelet antibodies such as anti-GP IIb/IIIa or anti-GP Ib/IX, coat the surface of platelets. These antibody-coated platelets are recognized and destroyed by macrophages in the spleen and liver, contributing to thrombocytopenia.

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A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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