(Select all that apply): A nurse is assessing a patient with thrombocytopenia.
Which interventions are appropriate for this patient? Select all that apply.

Administer platelet transfusion.

Encourage high-intensity physical activity.

Monitor for signs of bleeding.

Administer heparin therapy.

Educate the patient on infection prevention.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale:

"Administer platelet transfusion." Rationale: This is an appropriate intervention for a patient with thrombocytopenia, especially if they are experiencing severe bleeding or have a very low platelet count.

Platelet transfusion can help increase the platelet count and prevent or stop bleeding.

Choice B rationale:

"Encourage high-intensity physical activity." Rationale: This intervention is not appropriate for a patient with thrombocytopenia.

High-intensity physical activity can increase the risk of bleeding in these patients due to the low platelet count.

Choice C rationale:

"Monitor for signs of bleeding." Rationale: This is an essential intervention for a patient with thrombocytopenia.

Monitoring for signs of bleeding, such as petechiae, ecchymosis, or mucosal bleeding, allows for early detection and intervention.

Choice D rationale:

"Administer heparin therapy." Rationale: This intervention is not appropriate for a patient with thrombocytopenia, especially if the thrombocytopenia is immune-mediated, as heparin can exacerbate the condition.

Choice E rationale:

"Educate the patient on infection prevention." Rationale: This is an appropriate intervention for a patient with thrombocytopenia.

Patients with low platelet counts are at increased risk of infection, so education on infection prevention measures, such as hand hygiene and avoiding sick individuals, is essential.

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Correct Answer is ["B","C","D"]

Explanation

Confusion.

C. Swelling of affected limbs.

D. Blood in stool (hematochezia)

Choice A rationale:

Fever.

Rationale: Fever is not typically associated with thrombocytopenia itself.

Thrombocytopenia primarily affects the platelet count and can result in bleeding symptoms, but fever is not a direct symptom of thrombocytopenia.

Choice B rationale:

Confusion.

Rationale: Confusion can be a symptom of thrombocytopenia, especially if bleeding occurs in the brain, leading to neurological symptoms.

Thrombocytopenia can cause intracranial bleeding, which may result in confusion and altered mental status.

Choice C rationale:

Swelling of affected limbs.

Rationale: Swelling of affected limbs is not a common symptom of thrombocytopenia.

Thrombocytopenia primarily leads to bleeding symptoms, such as easy bruising, petechiae, or hematomas, rather than swelling.

Choice D rationale:

Blood in stool (hematochezia)

Rationale: Blood in stool (hematochezia) is a potential symptom of thrombocytopenia.

When platelet counts are low, it can lead to gastrointestinal bleeding, which may manifest as blood in the stool.

Choice E rationale:

Elevated liver function tests (ALT and AST)

Rationale: Elevated liver function tests (ALT and AST) are not typically associated with thrombocytopenia.

Thrombocytopenia is primarily related to platelet counts, while elevated liver function tests suggest liver dysfunction, which may have different causes.

A. Monitoring the patient's neurological status. B. Checking the patient's vital signs. C. Administering corticosteroids. D. Preparing the patient for a splenectomy.

Correct Answer is B

Explanation

Choice A rationale:

Monitoring the patient's neurological status While monitoring neurological status is important in patient care, it is not the immediate priority when a patient with thrombocytopenia reports hematochezia (bloody stools), fatigue, and abdominal pain.

Checking vital signs helps assess the patient's overall stability and guides immediate interventions.

Choice C rationale:

Administering corticosteroids Administering corticosteroids may be a treatment option for certain types of thrombocytopenia, but it is not the initial priority in the assessment of a patient presenting with hematochezia, fatigue, and abdominal pain.

First, the nurse needs to assess the patient's condition and vital signs to determine the severity of the situation.

Choice D rationale:

Preparing the patient for a splenectomy Preparing a patient for a splenectomy is a significant intervention and should not be the initial priority in this case.

It may be considered as a treatment option in some cases of thrombocytopenia, but it should not take precedence over assessing the patient's vital signs and overall condition.

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(Select all that apply): A nurse is assessing a patient with thrombocytopenia.Which interventions are appropriate for this patient? Select all that apply.

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Naxlex Comprehensive Predictor Exams

(Select all that apply):A nurse is assessing a patient with suspected thrombocytopenia.Which findings should the nurse consider as potential signs or symptoms of thrombocytopenia? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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Correct Answer is B

Explanation

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(Select all that apply): A nurse is assessing a patient with thrombocytopenia.
Which interventions are appropriate for this patient? Select all that apply.