02 The Client with Platelet Disorders

[John]

The Client with Platelet Disorders

29. Which of the following nursing interventions is appropriate for a client with a platelet count of 31,000/mm³?

1. Pad sharp surfaces to avoid minor trauma when walking.

A client with a platelet count of 30,000 to 50,000/mm³

is susceptible to bruising with minor trauma.

Padding areas that the client might bump, scratch, or hit

may help prevent minor trauma.

2. Assess for spontaneous petechiae in the extremities.

A platelet count of 15,000 to 30,000/mm³

may result in spontaneous petechiae and bruising, especially on the extremities.

Safety measures to pad surfaces would still be used,

but the focus would be on assessing for new spontaneous petechiae.

3. Keep the room darkened.

Keeping the room dark does not help the client with a low platelet count.

4. Check for blood in the urine.

When the count is lower than 20,000/mm³,

the client is at risk for spontaneous bleeding from the mucous membranes (oral, nasal, urinary, and rectal) and intracranial bleeding.

30. A client with a history of systemic lupus erythematosus was admitted "With a severe viral respiratory infection and diffuse petechiae. Based on these data,

it is most important that the nurse further eval‎uate the client's recent

1. quality and quantity of food intake.

Petechiae are not caused by poor nutrition.

2. type and amount of fluid intake.

3. weakness, fatigue, and ability to get around.

Because of poor food and fluid intake or weakness and fatigue,

the client may have gotten bruises from falling or bumping into things,

but not petechiae.

4. length and amount of menstrual flow.

A recent viral infection in a female client between the ages of 20 and 30 years with a history of systemic lupus erythematosus and an insidious onset of diffuse petechiae are hallmarks of idiopathic thrombocytopenic purpura (ITP).

It is important to ask whether the client's recent menses have been lengthened or are heavier.

Determining her ability to clot can help determine her risk for increased bleeding tendency until a platelet count is drawn.

31. When a client with thrombocytopenia complains of a severe headache,

the nurse interprets that this may indicate which of the following?

1. Stress of the disease.

2. Cerebral bleeding.

When the platelet count is very low,

red blood cells leak out of the blood vessels and into the tissue.

If the blood pressure is elevated and the platelet count falls to less than 15,000/mm³, internal bleeding in the brain can occur.

A severe headache occurs from meningeal irritation

when blood leaks out of the cerebral vasculature.

When a client has thrombocytopenia, the nurse should always assess

for cerebral bleeding by checking vital signs and performing neurologic checks.

3. A migraine headache.

4. Sinus congestion.

32. The nurse eval‎uates that the client correctly understands how to report signs of bleeding when she makes which of the following statements?

1. "Petechiae are large red skin bruises."

Small, flat, red pinpoint lesions are petechiae.

2. "Ecchymoses are large purple skin bruises."

Large purplish skin lesions caused by hemorrhage are called ecchymoses.

3. "Purpura is an open cut on the skin."

Numerous petechiae result in a reddish, bruised appearance called purpura.

4. "Abrasions are small pinpoint red dots on the skin.

An abrasion is a wound caused by scraping.

petechiae	Small, flat, red pinpoint lesions
ecchymoses	Large purplish skin lesions caused by hemorrhage
purpura	Numerous petechiae result in a reddish, bruised appearance
abrasion	a wound caused by scraping

33. The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations?

1. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies.

Previously the cause was unknown, but recent research suggests that ITP occurs when antibody-coated platelets are identified as foreign bodies

and destroyed by macrophages in the spleen.

2. It is believed that the liver identifies the platelets as foreign bodies.

3. It is now believed that the syndrome is related to an underactive immune system.

4. The cause is unknown.

It is not an idiosyncratic response

and is not related to a depressed immune system.

34. The nurse should instruct the client with a platelet count of less than 150,000/ micro L to avoid which of the following activities?

1. Ambulation.

Clients should avoid any activity that causes straining to evacuate the bowel.

Clients can ambulate, but pointed or sharp surfaces should be padded.

2. Valsalva's maneuver.

When the platelet count is less than 150,000/mL, prolonged bleeding can occur from trauma, injury, or straining such as with the Valsalva maneuver.

3. Visiting with children.

Clients can visit with their families

but should avoid any scratches, bumps, or scraps.

4. Semi-Fowler's position.

Clients can sit in a semi-Fowler's position

but should change positions to promote circulation and check for petechiae.

35. If a client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superficial injury,

the nurse recognizes that this clinical manifestation most likely reflects

1. a prothrombin time (PT) of 10 seconds.

The PT eval‎uates the extrinsic pathway (coagulation factor VIII)

and represents the time it takes to form a firm clot.

The PT value is normal in severe thrombocytopenia.

2. an activated partial thromboplastin time (aPTT) of 40 seconds.

The aPTT eval‎uates the intrinsic and common coagulation pathway

and represents the time it takes to form a firm clot.

It is basically the same as the PTT

but is considered to be more reliably reproducible and faster.

The aPTT value is normal in severe thrombocytopenia.

3. a ble eding time of 8 minutes.

Bufferin contains aspirin, which is an antiplatelet agent

that prevents platelet aggtegation. After a 300-mg dose of aspirin,

the bleeding time can be prolonged as long as 5 days.

One of the best methods to check for platelet deficiency

is the bleeding time test. A number of other drugs, such as alcohol, sulfonamides, and thiazide diuretics, can prolong the bleeding time.

4. a coagulation time (CT) of 8 minutes.

The CT or Lee-White coagulation time is normal,

but it is an old and insensitive test that does not rule out a coagulation defect.

36. A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating platelets.

The nurse recognizes a knowledge deficit

when the client makes which of the following statements?

1. "I need to stop flossing and throwaway my hard toothbrush."

The client needs to stop flossing and throwaway his hard toothbrush,

which can lead to bleeding of the gums.

2. "I am glad that my report turned out normal."

The client who states that the test results are normal

has only heard that the bone marrow is functioning.

The etiology is in the destruction of circulating platelets.

Further tests must be completed to determine the cause

(eg. a coating of the platelets with antibodies that are seen as foreign bodies).

The bone marrow result does rule out other potential diagnoses such as anemia, leukemia, or myeloproliferative disorders that involve bone marrow depression.

3. "Now I know why I have all these bruises."

The destruction of the circulating platelets accounts for the easy bruising

and the need to protect oneself from further bruising.

4. "I shouldn't jump off that last step anymore."

The client should not jump or increase exertion of joints,

which may lead to bleeding in the joints and joint pain.

37. Which early symptom does the nurse observe in a client with thrombocytopenia who has developed a hemorrhage?

1. Tachycardia.

The nurse observes tachycardia in the hemorrhaging client

because the heart beats faster to compensate for decreased circulating volume and decreased numbers of oxygen-carrying red blood cells.

The degree of cardiopulmonary distress and anemia

will be related to the amount of hemorrhage

that occurred and the period of time over which it occurred.

2. Bradycardia.

Bradycardia is a late symptom of hemorrhage;

it occurs after the client is no longer able to compromise

and is debilitating further into shock.

If it is left untreated, the client will die from cardiovascular collapse.

3. Decreased PaCO₂.

Decreased PaCO₂ is a late symptom of hemorrhage,

after transport of oxygen to the tissue has been affected.

4. Narrowed pulse pressure. 

A narrow pulse pressure is not an early sign of hemorrhage.

38. The client with ITP asks the nurse why she has to take steroids.

Which is the nurse's best response?

1. Steroids destroy the antibodies and prolong the life of platelets.

2. Steroids neutralize the antigens and prolong the life of platelets.

3. Steroids increase phagocytosis and increase the life of the platelets.

The steroids also suppress the binding of the autoimmune antibody

to the platelet surface.

Steroids do not destroy the antibodies on the platelets, neutralize antigens, or increase phagocytosis.

4. Steroids alter the spleen's recognition of platelets and increase the life of the platelets.

ITP is treated with steroids to suppress the splenic macro phages

from phagocytizing the antibody-coated platelets,

which are recognized as foreign bodies, so that the platelets live longer.

39. A client is to be discharged on prednisone.

Which of the following statements indicates that the client understands important concepts about the medication therapy?

1. "I need to take the medicine in divided doses at morning and bedtime."

Prednisone should be taken in the morning

because it can cause insomnia

and because exogenous corticosteroid suppression of the adrenal cortex

is less when it is administered in the morning.

2. "I am to take 40 mg of prednisone for 2 months and then stop."

Prednisone must never be stopped suddenly.

It must be tapered off to allow for the adrenal cortex to recover

from drug-induced atrophy so that it can resume its function.

3. "I need to wear or carry identification that I am taking prednisone."

The client needs to wear information containing the name of the drug, dosage, physician and contact information, and emergency instructions,

because additional corticosteroid drug therapy

would be needed during emergency situations.

4. "Prednisone will give me extra protection from colds and flu.

Prednisone suppresses the immune response and masks infections.

It does not provide extra protection against infection.

40. When teaching the client older than 50 years of age who is receiving long-term prednisone therapy, which of the following actions does the nurse recommend?

1. Take the prednisone with food.

Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food.

In some instances, the client may be advised to take a prescribed antacid prophylactically.

2. Take over-the-counter drugs as needed.

The client should never take over- the-counter drugs

without notifying the physician who prescribed the prednisone.

3. Exercise three to four times a week.

The client should ask the physician about the amount and kind of exercise because of the need to establish baseline physical values

before starting an exercise program and because of the increased potential

for comorbidity with increasing age.

4. Eat foods that are low in potassium.

The client should eat foods that are high in potassium to prevent hypokalemia.



41. The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy.

What type of exercise is most appropriate for this client?

1. Floor exercises.

Floor exercises do not provide for the weight bearing.

2. Stretching.

Stretching is appropriate but does not offer sufficient weight bearing.

3. Running.

Running provides for weight bearing

but is hard on the joints and may cause bleeding.

4. Walking.

The best exercise for women who are on longterm corticosteroid therapy

is a low-impact weight bearing exercise such as walking or weight lifting.

42. A client with a history of acquired thrombocytopenia has been instructed on

how to prevent and control hemorrhage.

Which statement indicates that the client needs further intervention?

1. "I can apply direct pressure over small cuts for at least 5 to 10 minutes

to stop a venous bleed."

Clients with thrombocytopenia can apply pressure for 5 to 10 minutes

over a small, superficial cut.

2. "I can count the number of tissues saturated to detect blood loss during a nosebleed."

The client needs further teaching if she thinks that the number of tissues saturated represents all of the blood lost during a nosebleed.

During a nosebleed, a significant amount of blood can be swallowed and go undetected. It is important that clients with severe thrombocytopenia do not take a nosebleed lightly.

3. "I can take hormones to decrease blood loss during menses."

Clients with thrombocytopenia can take hormones

to suppress menses and control menstrual blood loss.

4. "I can count the number of sanitary napkins to detect excess blood loss

during menses."

Clients can also count the number of saturated sanitary napkins to approximate blood loss during menses. Some authorities estimate that a completely soaked sanitary napkin holds 50 mL.

43. Which of the following clinical manifestations does the nurse find in the client who has systemic adverse effects from long-term corticosteroid therapy?

1. Weight gain.

2. High serum albumin.

3. Low sodium.

4. Hyperkalemia.

Adverse effects of prednisone are weight gain, retention of sodium and fluids with hypertension and cushingoid features, a low serum albumin, suppressed inflammatory processes with masked symptoms, and osteoporosis.

A diet high in protein, potassium, calcium, vitamin D, and vitamin C

is recommended. 

44. Platelets should not be administered under which of the following conditions?

1. The platelet bag is cold.

             Platelets cannot survive cold temperatures.

2. The platelets are 2 days old.

3. The platelet bag is at room temperature.

4. The platelets are 12 hours old.

The platelets should be stored at room temperature

and last for no more than 5 days.

45. The nurse is preparing to administer platelets.

The nurse should

1. check the ABO compatibility.

ABO compatibility is not a necessary requirement,

but human leukocyte antigen (HlA) matching of lymphocytes

may be completed to avoid development of anti-HIA antibodies

when multiple platelet transfusions are necessary.

2. administer the platelets slowly.

Platelets should be administered as fast as can be tolerated by the client

to avoid aggregation.

3. gently rotate the bag.

The bag containing platelets needs to be gently rotated to prevent clumping.

4. use a whole blood tubing set.

Most institutions use tubing especially for platelets

instead of tubing for blood and blood products.

46. Which of the following indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client

1. breathes in through the nose and out through the mouth.

2. breathes in through the mouth and out through the nose.

3. uses diaphragmatic breathing in the lying, sitting, and standing positions.

4. takes a deep breath in through the nose holding it for 5 seconds,

and blows out through pursed lips.

The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose and hold it for 5 seconds, then blow it out through pursed lips.

The goal is to fully expand and empty the lungs for pulmonary hygiene.

47. A client is scheduled for an elective splenectomy.

Before the client goes to surgery, the nurse's final assessment is the client's

1. empty bladder.

The client should have emptied the bladder before receiving preoperative medications so that the bladder is empty when it is time for transport into the operating room.

2. signed consent.

The client should have signed the consent before the transport time

so that if there were any questions or concerns there was time to meet

with the surgeon. Also, the consent form must be signed before any sedative medications are given.

3. vital signs.

An elective surgical procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for. The first assessment that will be completed in the preoperative holding area or operating room will be the client's vital signs.

4. name band.

The client's name band should be placed as soon as the client arrives in the perioperative setting, and it remains in place through discharge.

48. When receiving a client from the postanesthesia care unit,

what should the nurse assess after obtaining vital signs?

1. Nasogastric drainage.

The nasogastric tube should be connected,

but this can wait until the dressing has been checked.

2. Urinary catheter.

A urinary catheter is not needed.

3. Dressing.

After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dressing should be checked often; if drainage is present,

a circle should be drawn around the drainage and the time noted

to help determine how fast bleeding is occurring.

4. Need for pain medication.

The last pain medication administration and the patient's current pain level should be communicated in the exchange report.

Checking for hemorrhage is a greater priority than assessing pain level.

49. The client's family asks why the client has a nasogastric tube.

A nasogastric tube is used to

l. move the stomach away from where the spleen was removed.

The stomach does not need to be manipulated away from the spleen postoperatively, nor would a nasogastric tube accomplish this.

2. irrigate the operative site.

The nasogastric tube drains gastric contents and air in the stomach;

it is not in the operative site, and therefore cannot be used to irrigate it.

3. decrease abdominal distention.

A splenectomy may involve manipulation of the upper abdominal organs

such as diaphragm, stomach, liver, spleen, and small intestines.

Manipulation of these organs and resulting inflammation

lead to a slowed peristalsis.

A nasogastric tube is placed to decrease abdominal distention

in the immediate postoperative phase.

4. assess for the gastric pH as peristalsis returns.

The gastric juices are not checked as an indicator that peristalsis has returned; instead, the bowel sounds are auscultated in all four quadrants to indicate the return of peristalsis.



50. A client who had a splenectomy is being discharged. Of the following discharge instructions, which is most specific to the client's surgical procedure?

1. Do not drive.

All clients who have had major abdominal surgery usually receive discharge instructions not to drive because the stomach muscles are not strong enough to brake hard or quickly after the abdominal muscles have been separated.

2. Alternate rest and activity.

All clients need to pace activity and rest when going home after major surgery. Rest and sleep allow the growth hormone to repair the tissue,

and activity allows the energy and strength to build endurance and muscle strength.

3. Make an appointment for the staples to be removed.

An appointment is usually made to see the surgeon in the office 1 week after discharge for follow up and to remove sutures or staples if this has not already been done.

4. Report early signs of infection.

Clients who have had a splenectomy are especially prone to infection.

The reduction of immunoglobulin M leaves the client

especially at risk for immunologic deficiency infections.



51. What is the earliest and most obvious clinical manifestation

in a client with acute disseminated intravascular coagulation (DlC)?

1. Severe shortness of breath.

2. Bleeding without history or cause.

There is no well-defined sequence for acute DIC other than that the client starts bleeding without a history or cause and does not stop bleeding.

3. Orthopnea.

4. Hematuria.

Later signs may include severe shortness of breath, hypotension, pallor, petechiae, hematoma, orthopnea, hematuria, vision changes, and joint pain.

52. Which of the following is contraindicated for a client diagnosed with DlC?

1. Treating the underlying cause.

2. Administering heparin.

3. Administering Coumadin.

4. Replacing depleted blood products.

             DIC has not been found to respond to oral anticoagulants such as Coumadin.

Treatments for DIC are controversial but include treating the underlying cause, administering heparin, and replacing depleted blood products.

53. A client with DlC develops clinical manifestations of microvascular thrombosis.

The nurse should assess the client for

2. focal ischemia.

Clinical manifestations of microvascular thrombosis

are those that represent a blockage of blood flow and oxygenation

to the tissue which results in eventual death of the organ.

Examples of microvascular thrombosis include acute respiratory distress syndrome (ARDS), focal ischemia, superficial gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium, and coma.

1. hemoptysis.

3. petechiae.

4. hematuria.

Hemoptysis, petechiae, and hematuria are signs of hemorrhage.

54. Which of the following is an assessment finding associated with internal bleeding with DIC?

1. Bradycardia.

2. Hypertension.

The patient would be tachycarctic and hypotensive.

3. Increasing abdominal girth.

As blood collects in the peritoneal cavity it causes dilatation and distention, which is reflected in increased abdominal girth.

4. Petechiae.

Petechiae reflect bleeding in the skin.