After noting that a patient with leukemia has thrombocytopenia, which action will the nurse plan to take?
Palpate lymph nodes for swelling.
Check temperature for elevation.
Inspect skin for bruising or petechiae.
Examine oral mucosa for ulceration.
The Correct Answer is C
Choice A rationale:
Palpating lymph nodes for swelling is not directly related to thrombocytopenia. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to easy bruising and bleeding. Checking lymph nodes is more relevant in assessing for infection or malignancy.
Choice B rationale:
Checking temperature for elevation is important for assessing infection, which could be a cause of thrombocytopenia. However, in this context, inspecting the skin for bruising or petechiae is more specific to thrombocytopenia. Petechiae are small, red or purple dots that appear on the skin when platelet count is low.
Choice D rationale:
Examining oral mucosa for ulceration is essential in the assessment of conditions like oral cancer or infection. While thrombocytopenia could lead to bleeding in the oral mucosa, it is not the most specific or immediate concern in a patient with known thrombocytopenia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Purpura refers to purple or red discolorations on the skin caused by bleeding underneath the skin. It is larger than petechiae and ecchymosis and could be a sign of a more serious underlying condition. Petechiae are small, red or purple dots that appear on the skin due to minor bleeding from broken capillaries. In the context of leukemia and thrombocytopenia (low platelet count), petechiae are common due to impaired clotting mechanisms.
Choice B rationale:
Bruising occurs due to damage to blood vessels underneath the skin, resulting in the leakage of blood into the surrounding tissues. Bruises are typically larger than petechiae and can occur with various conditions, including trauma. In this case, the small 1-mm red macules are more indicative of petechiae.
Choice D rationale:
Ecchymosis refers to a larger area of subcutaneous bleeding or bruising. It is larger than both petechiae and purpura and often results from more significant trauma or bleeding disorders. The description of multiple 1-mm red macules is characteristic of petechiae rather than ecchymosis.
Correct Answer is C
Explanation
Choice A rationale:
Neutropenia is a condition characterized by a low number of neutrophils, a type of white blood cell. Neutropenic patients are at increased risk of infections, but neutropenia does not cause specific changes in the tongue surface. The smooth and shiny tongue surface described in the question is not indicative of neutropenia.
Choice B rationale:
Polycythemia is a condition characterized by an abnormally high concentration of hemoglobin in the blood. It can cause the skin to appear reddish or flushed, but it does not directly cause changes in the tongue surface such as smoothness and shininess.
Choice C rationale:
Pernicious anemia is a type of anemia caused by a deficiency of vitamin B12, which is essential for the formation of red blood cells and the maintenance of the nervous system. One of the characteristic signs of pernicious anemia is glossitis, which is inflammation of the tongue that can make the tongue appear smooth and shiny. This finding aligns with the description provided in the question.
Choice D rationale:
Elevated estrogen levels can cause changes in the skin, such as increased pigmentation or the development of spider veins, but they do not directly cause changes in the tongue surface as described in the question.
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