A nurse receives report on a client who is diagnosed with thrombotic thrombocytopenic purpura (TTP). Understanding the complications associated with this condition, which assessment is the priority for the nurse to complete for this client?
Assess pedal pulses
Assess nutritional status
Assess urine output
Assess liver function
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. MS is a chronic autoimmune disorder affecting the central nervous system (CNS), specifically the brain and spinal cord. It typically presents with a wide range of neurological symptoms such as blurred vision, sensory disturbances, weakness, and difficulties with coordination and balance. However, MS does not typically present with a sudden onset of ascending numbness and weakness starting in the feet and moving upwards.
B. GBS is an acute autoimmune disorder where the immune system attacks the peripheral nervous system. It often starts with numbness, tingling, and weakness in the feet and legs, which then
progresses symmetrically upwards to involve the upper limbs and potentially affect respiratory muscles. This ascending pattern of weakness is characteristic of GBS, making it the most likely diagnosis in this scenario.
C. Myasthenia gravis is a chronic autoimmune disorder affecting neuromuscular junctions, leading to muscle weakness and fatigue, especially with repetitive use. It typically presents with fluctuating muscle weakness that worsens with activity and improves with rest. The pattern of ascending numbness and weakness seen in the scenario does not align with the typical presentation of myasthenia gravis.
D. Parkinson's disease is a progressive neurological disorder primarily affecting movement. It presents with symptoms such as tremors, bradykinesia (slowness of movement), rigidity, and postural instability. It does not typically cause numbness or a symmetrical ascending pattern of weakness as described in the scenario.
Correct Answer is B
Explanation
A. Headache is a common side effect of nitroglycerin due to its vasodilatory effects, especially in the head. Most headaches associated with nitroglycerin are mild and transient. Patients are generally advised to continue using the medication as prescribed unless the headache is severe or persistent.
B. Nitroglycerin tablets are used for the immediate relief of angina symptoms. If the first tablet does not adequately relieve chest pain within 5 minutes, the patient can take a second tablet. If the pain persists after the second tablet, emergency medical attention should be sought. However, it's important to note that the maximum number of tablets that can be taken within a short period should be specified by the healthcare provider, typically 2 or 3 tablets in 15 to 30 minutes.
C. Nitroglycerin can cause orthostatic hypotension, which is a drop in blood pressure upon standing up. This can lead to dizziness or fainting. Therefore, patients should be advised to stand up slowly after taking nitroglycerin to minimize the risk of falls or injury.
D. Nitroglycerin tablets are sensitive to light, heat, and moisture, which can reduce their effectiveness over time. Therefore, it's recommended to replace nitroglycerin tablets every 3 to 6 months to ensure potency and effectiveness.
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