How it Works
Try Naxlex NCLEX-RN (14-day Free-Trial)

Nursing Assessment of Thrombocytopenia

- The nursing assessment of thrombocytopenia involves collecting subjective and objective data from the patient and family to identify the nursing diagnoses and plan the care for the patient.

- Subjective data include information about the patient’s history of thrombocytopenia or bleeding disorders; current medications, herbal supplements, or dietary intake; recent infections, surgeries, traumas, or transfusions; symptoms of bleeding such as epistaxis, gingival bleeding, hematuria

Some additional sentences to complete the response are:

  • hematochezia, menorrhagia, or petechiae; symptoms of anemia such as fatigue, weakness, pallor, or dyspnea; symptoms of infection such as fever, chills, sore throat, or cough; symptoms of organ dysfunction such as abdominal pain, nausea, vomiting, jaundice
  • Objective data include vital signs; skin color and temperature; mucous membranes; presence and location of petechiae, purpura or ecchymoses; signs of bleeding from any site; neurological status; abdominal examination; peripheral pulses and edema; laboratory results such as CBC with platelet count and peripheral blood smear; coagulation studies; antibody tests; renal function tests; liver function tests; imaging studies such as abdominal ultrasound chest x-ray or CT scan.

Questions on Nursing Assessment of Thrombocytopenia

Correct Answer is B

Explanation

"Thrombocytopenia in ITP is triggered by heparin-platelet factor 4 complexes." Rationale: This statement is incorrect. Heparin-induced thrombocytopenia (HIT) involves the formation of antibodies against heparin-platelet factor 4 complexes, leading to platelet activation and a decrease in platelet count. This is a different condition than ITP.

Correct Answer is B

Explanation

"Thrombocytopenia-related bleeding is a result of heparin therapy." Rationale: This statement is inaccurate. Thrombocytopenia related to heparin therapy is known as heparin-induced thrombocytopenia (HIT), and it occurs due to an immune response to heparin, not the same mechanism as in thrombocytopenia.

Correct Answer is ["A","C","E"]

Explanation

"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.

Correct Answer is B

Explanation

"A platelet count above 1,000,000/uL is typical in healthy individuals." Rationale: This statement is incorrect. A platelet count above 1,000,000/uL is considered abnormally high and can lead to an increased risk of clot formation, which is not typical in healthy individuals. The normal range is much lower.

Correct Answer is B

Explanation

"Thrombocytopenia results from the inhibition of platelet aggregation by chemotherapy." Rationale: This statement is not accurate. Chemotherapy primarily affects platelet production and can lead to a decrease in platelet count. It does not typically inhibit platelet aggregation.

Correct Answer is B

Explanation

"The platelet count does not affect bleeding symptoms." Rationale: This statement is incorrect. Platelet count plays a significant role in the body's ability to form blood clots and prevent bleeding. Low platelet counts can lead to bleeding symptoms, as described in the patient's presentation of mucosal bleeding. Platelet count is indeed relevant in assessing and managing bleeding risk in thrombocytopenia.

Correct Answer is B

Explanation

"Bleeding risk increases with a platelet count above 150,000/uL." Rationale: This statement is incorrect. A platelet count above 150,000/uL is within the normal range and does not increase the risk of bleeding. Instead, it may increase the risk of thrombosis (excessive clotting)

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

Explanation

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.

Schistocytes confirm the absence of bleeding risk. Rationale: This statement is incorrect. Schistocytes do not confirm the absence of bleeding risk. While they are associated with conditions involving red blood cell damage, they do not provide information about the patient's platelet count, which is

<p>The size and shape of platelets on a peripheral blood smear The size and shape of platelets are important for diagnosing specific types of thrombocytopenia but are typically not the initial priority in the assessment. Identifying signs of infection or organ dysfunction takes precedence because th

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'

Prepare the client for immunosuppressant therapy Immunosuppressant therapy may be considered as a treatment option for certain types of thrombocytopenia, but it is not the initial intervention when the client has active bleeding and weakness. The immediate focus should be on bleeding control and sym

Monitor the patient's response to treatment by checking the skin color and temperature. While monitoring the patient's response to treatment is essential, checking skin color and temperature alone may not provide comprehensive information about thrombocytopenia management. Monitoring platelet counts

Applying pressure to any bleeding site and elevating the affected area. This is the essential nursing intervention to prevent and manage bleeding in clients with thrombocytopenia. Applying pressure to a bleeding site helps control bleeding, and elevating the affected area can reduce swelling and min

<p>Advise the patient to skip monitoring platelet counts. Regular monitoring of platelet counts is essential for patients with thrombocytopenia to assess the effectiveness of treatment and identify any potential complications. Advising the patient to skip monitoring is not appropriate and may lead t
Try Naxlex NCLEX-RN
(14 Day Free-Trial)

Search Here

Related Topics

More on Nursing

Free Nursing Study Materials

Access to all study guides and practice questions for nursing for free.

  • Free Nursing Study Trials
  • Free Nursing Video tutorials
  • Free Nursing Practice Tests
  • Free Exam and Study Modes
  • Free Nursing Revision Quizlets
Join Us Today