The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP) whose platelet count is 10,000/mm³. What assessment finding will the nurse report to the provider immediately?

The patient has scattered petechiae on bilateral lower extremities.

The patient has ecchymosis around their intravenous site.

Answer and Explanation

The Correct Answer is B

Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.

Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.

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Correct Answer is B

Explanation

Choice A reason: An arterial pH less than 7.3 indicates acidosis, which is common in diabetic ketoacidosis but not typical in hyperglycemic hyperosmolar syndrome. Patients with hyperglycemic hyperosmolar syndrome typically have a near-normal pH.

Choice B reason: Altered mental status is a significant clinical manifestation in hyperglycemic hyperosmolar syndrome due to severe hyperglycemia and the hyperosmolar state, which can lead to dehydration and impaired brain function.

Choice C reason: The presence of ketones in urine is more commonly associated with diabetic ketoacidosis rather than hyperglycemic hyperosmolar syndrome. The absence of significant ketonemia differentiates hyperglycemic hyperosmolar syndrome from diabetic ketoacidosis.

Choice D reason: Serum bicarbonate less than 15 mEq/L is indicative of metabolic acidosis, typically seen in diabetic ketoacidosis rather than hyperglycemic hyperosmolar syndrome, where bicarbonate levels are usually normal or slightly decreased.

A. Kussmaul breathing B. Positive Chvostek sign C. Hematemesis D. Distended jugular vein

Correct Answer is B

Explanation

Choice A reason: Kussmaul breathing is a sign of metabolic acidosis, not metabolic alkalosis. It is characterized by deep, labored breathing as the body tries to expel excess carbon dioxide.

Choice B reason: Positive Chvostek sign is an indication of hypocalcemia, which can be associated with metabolic alkalosis. It is a facial muscle twitch that occurs when the facial nerve is tapped.

Choice C reason: Hematemesis, or vomiting blood, is not a clinical manifestation of metabolic alkalosis. It is more related to gastrointestinal bleeding.

Choice D reason: Distended jugular veins are more commonly associated with conditions such as heart failure and fluid overload, not specifically with metabolic alkalosis.

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The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP) whose platelet count is 10,000/mm³. What assessment finding will the nurse report to the provider immediately?

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