The nurse is planning care for a client with immune thrombocytopenic purpura (ITP). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

Teach the client to avoid rectal and injection medications.

Teach the client about using an electric razor.

Prepare the client for a prescribed blood transfusion.

Teach the client to avoid constipation.

Explain the importance of avoiding taking sulfa-containing medications.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale

Clients with immune thrombocytopenic purpura (ITP) have a low platelet count, increasing the risk of bleeding. Avoiding rectal and injection medications minimizes the risk of mucosal damage and bleeding complications due to trauma caused by insertion or puncture. This precaution is especially critical as bleeding may not be easily controlled in these clients.

Choice B rationale

An electric razor prevents the risks associated with minor cuts or abrasions that could occur during shaving, which would be difficult to control due to low platelet levels. These injuries could lead to prolonged bleeding or bruising in ITP clients, compromising their safety further.

Choice C rationale

Blood transfusions are generally not indicated as routine interventions for ITP because platelet transfusions may not consistently improve platelet count due to antibody-mediated destruction. Treatment often focuses on medication and careful monitoring rather than transfusion.

Choice D rationale

Constipation should be avoided to reduce strain during bowel movements, which can result in rectal bleeding due to vascular damage in the area. The fragile nature of blood vessels in clients with ITP necessitates such preventive measures to avoid complications.

Choice E rationale

Sulfa-containing medications are known to exacerbate thrombocytopenia in some patients. Avoiding these medications minimizes further platelet depletion, which is vital for managing the condition and preventing severe bleeding episodes.

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Correct Answer is A

Explanation

Choice A rationale

Corticosteroids are used in thrombocytopenia because they suppress the immune response, particularly in immune thrombocytopenic purpura (ITP). They reduce platelet destruction by inhibiting autoantibody formation and increasing platelet lifespan. Normal platelet count ranges from 150,000 to 400,000/µL. Thrombocytopenia occurs when platelets drop below 150,000/µL, increasing bleeding risk. Corticosteroids can also decrease capillary permeability, minimizing petechiae and ecchymoses.

Choice B rationale

Diphenhydramine, an antihistamine, is used for allergic reactions but has no role in treating thrombocytopenia. It does not address the underlying immune or hematologic causes of low platelet counts. Its primary actions include H1 receptor antagonism, reducing histamine-mediated symptoms like itching and swelling. However, it lacks immunosuppressive or hematologic-stimulating effects essential for managing thrombocytopenia.

Choice C rationale

Desmopressin (DDAVP) is a synthetic antidiuretic hormone analog used for certain bleeding disorders like von Willebrand disease or mild hemophilia A. It increases factor VIII and von Willebrand factor levels, improving clotting. However, it is not indicated for thrombocytopenia as it does not address platelet count deficiencies or immune-mediated platelet destruction.

Choice D rationale

Hydrochlorothiazide (HCTZ) is a thiazide diuretic used for hypertension and edema. Its mechanism of action involves inhibiting sodium reabsorption in the distal tubule, promoting diuresis. HCTZ has no effect on platelet counts or immune mechanisms and is not used in thrombocytopenia. Its side effects, like electrolyte imbalances, may complicate patient management.

A. "This medication makes your kidneys work harder, so you may experience increased urine production.”. B. "Stop taking the medication immediately if you notice any edema in your legs.”. C. "You will need to have monthly blood specimens obtained to check your potassium level.”. D. "Report to your healthcare provider if you experience any constipation or abdominal pain.”.

Correct Answer is D

Explanation

Choice A rationale

Amlodipine, a calcium channel blocker, primarily acts on vascular smooth muscles to reduce blood pressure. It does not directly affect renal function or significantly increase urine output. This statement reflects a misunderstanding of the drug's mechanism of action.

Choice B rationale

Edema, a common side effect of amlodipine, is due to vasodilation and capillary leakage, particularly in lower extremities. However, sudden discontinuation of the medication may lead to rebound hypertension and should be avoided. Reporting side effects is crucial for alternative management.

Choice C rationale

Amlodipine does not necessitate routine potassium monitoring as it does not significantly affect potassium homeostasis. This requirement is more commonly associated with potassium-wasting diuretics or renin-angiotensin-aldosterone system modulators.

Choice D rationale

Constipation and abdominal pain, although less common, may occur due to gastrointestinal motility changes caused by smooth muscle relaxation. Prompt reporting ensures timely assessment and potential treatment modifications to enhance adherence.

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The nurse is planning care for a client with immune thrombocytopenic purpura (ITP). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

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