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:
While pregnancy can contribute to increased blood pressure, it is not the priority question in this scenario. The sudden rise in blood pressure could indicate a hypertensive crisis, which needs immediate attention.
Choice B rationale:
Urination is not directly related to sudden rises in blood pressure. While urinary issues could be a sign of certain conditions, they are not the priority when dealing with a hypertensive emergency.
Choice C rationale:
A sudden rise in blood pressure can lead to symptoms such as headache and confusion, which could indicate a hypertensive crisis. This question is crucial to assess neurological symptoms, which can be indicative of target organ damage due to hypertension.
Choice D rationale:
Antiseizure medications are not directly related to sudden increases in blood pressure. Neurological symptoms (like those in choice C) are more indicative of a hypertensive crisis and require immediate attention.
Correct Answer is D
Explanation
Choice A rationale:
Triple-drug therapy is not the standard treatment for pernicious anemia after a gastrectomy. Pernicious anemia is primarily caused by vitamin B12 deficiency due to the absence of intrinsic factor, which is essential for vitamin B12 absorption.
Choice B rationale:
IV therapy is a broad term and does not specify the treatment for pernicious anemia. In the context of pernicious anemia, cobalamin replacement therapy administered via intramuscular injections is the preferred treatment.
Choice C rationale:
Quadruple-drug therapy is not a recognized treatment for pernicious anemia. The primary treatment for pernicious anemia involves cobalamin replacement therapy to address the vitamin B12 deficiency.
Choice D rationale:
Cobalamin replacement therapy is the appropriate treatment for pernicious anemia after a gastrectomy. Since the patient lacks intrinsic factor, which is necessary for vitamin B12 absorption, cobalamin replacement therapy bypasses the need for intrinsic factor and provides the necessary vitamin B12 directly.
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