Choice A rationale:

"ITP results from decreased platelet production in the bone marrow." Rationale: This statement is not accurate.

Immune Thrombocytopenic Purpura (ITP) is primarily a disorder of platelet destruction, not decreased production in the bone marrow.

In ITP, autoantibodies target platelets, leading to their destruction by macrophages.

Choice B rationale:

"In ITP, autoantibodies mark platelets for destruction by macrophages." Rationale: This is the correct answer.

ITP is an autoimmune disorder where the immune system produces autoantibodies that attach to platelets, tagging them for destruction by macrophages in the spleen and liver.

Choice C rationale:

"ITP is characterized by impaired cleavage of von Willebrand factor." Rationale: This statement is not accurate.

Impaired cleavage of von Willebrand factor is a characteristic of von Willebrand disease, a different bleeding disorder, not ITP.

Choice D rationale:

"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.

Choice A rationale:

"Spontaneous bleeding in thrombocytopenia is due to excessive clotting." Rationale: This statement is not accurate.

Thrombocytopenia is characterized by a low platelet count, which impairs the blood's ability to form clots.

Spontaneous bleeding occurs because there are not enough platelets to participate in clot formation.

Choice B rationale:

"Immune-mediated destruction of platelets leads to spontaneous bleeding." Rationale: This is the correct answer.

In thrombocytopenia, especially immune thrombocytopenic purpura (ITP), the immune system destroys platelets, leading to a decreased platelet count.

This makes the patient more prone to spontaneous bleeding.

Choice C rationale:

"Bleeding occurs in thrombocytopenia due to increased platelet production." Rationale: This statement is incorrect.

Thrombocytopenia is characterized by a decreased platelet count, not increased production.

Choice D rationale:

"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.

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.

Choice A rationale:

"A normal platelet count is below 50,000/uL." Rationale: This statement is incorrect.

A platelet count below 50,000/uL is considered low and may indicate thrombocytopenia.

However, it is not within the normal range.

The normal platelet count range is higher.

Choice B rationale:

"The normal platelet count range is 150,000/uL to 400,000/uL." Rationale: This statement is accurate.

The normal platelet count range typically falls between 150,000/uL to 400,000/uL.

Platelets play a crucial role in blood clotting, and this range reflects the normal quantity needed for proper clot formation and prevention of excessive bleeding.

Choice C rationale:

"Platelet counts below 10,000/uL are considered normal." Rationale: This statement is incorrect.

A platelet count below 10,000/uL is extremely low and indicates severe thrombocytopenia.

It is not within the normal range.

Choice D rationale:

"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.

Choice A rationale:

"Increased platelet production due to chemotherapy." Rationale: This statement is not accurate.

Chemotherapy often suppresses bone marrow function, leading to a decrease in platelet production, not an increase.

Thrombocytopenia is a common side effect of chemotherapy due to reduced platelet production.

Choice B rationale:

"Immune-mediated platelet destruction caused by chemotherapy." Rationale: This statement is correct.

Thrombocytopenia in patients undergoing chemotherapy is often due to immune-mediated platelet destruction.

Chemotherapy can trigger an autoimmune response, leading to the destruction of platelets by the immune system.

Choice C rationale:

"Thrombocytopenia in this case is unrelated to chemotherapy." Rationale: This statement is unlikely to be true.

Thrombocytopenia occurring in a patient following chemotherapy is often directly related to the treatment.

While other factors may contribute, chemotherapy is a known cause of decreased platelet counts.

Choice D rationale:

"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.

Choice A rationale:

"The platelet count is likely within the normal range." Rationale: This statement is unlikely to be true.

Given that the patient is presenting with mucosal bleeding, including petechiae, purpura, and gingival bleeding, it suggests a potential problem with platelet function.

Platelet counts within the normal range do not typically lead to these bleeding symptoms.

Choice B rationale:

"The platelet count may be below 50,000/uL, indicating a risk of prolonged bleeding." Rationale: This statement is accurate.

The symptoms described (petechiae, purpura, and gingival bleeding) are indicative of thrombocytopenia, where the platelet count is typically below 50,000/uL.

This lower count increases the risk of prolonged bleeding and bruising.

Choice C rationale:

"The platelet count is typically above 100,000/uL in thrombocytopenia." Rationale: This statement is not accurate.

Thrombocytopenia is characterized by a decrease in platelet count, often below 100,000/uL, as seen in choice B.

A platelet count above 100,000/uL is not typical in thrombocytopenia.

Choice D rationale:

"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.

Choice A rationale:

"A platelet count below 100,000/uL is considered normal." Rationale: This statement is incorrect.

A normal platelet count typically ranges between 150,000 and 450,000/uL.

A platelet count below 100,000/uL is not considered normal and may indicate thrombocytopenia or another underlying issue.

Choice B rationale:

"A platelet count below 50,000/uL can result in prolonged bleeding." Rationale: This statement is correct.

Platelets are essential for normal blood clotting, and a platelet count below 50,000/uL can lead to an increased risk of bleeding, especially after minor trauma.

Severe bleeding risk typically occurs when the platelet count drops below 20,000/uL.

Choice C rationale:

"Platelet count has no impact on bleeding risk." Rationale: This statement is incorrect.

Platelet count directly affects bleeding risk.

A lower platelet count increases the risk of bleeding, while a higher count can lead to an increased risk of clot formation (thrombosis)

Choice D rationale:

"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)

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.

Choice A rationale:

Schistocytes suggest normal platelet function.

Rationale: This statement is incorrect.

Schistocytes are not related to platelet function.

Schistocytes are fragmented red blood cells, and their presence on a peripheral blood smear suggests mechanical damage to red blood cells, not platelets.

Choice B rationale:

Schistocytes are associated with thrombocytosis.

Rationale: This statement is incorrect.

Schistocytes are not associated with thrombocytosis, which is an elevated platelet count.

They are more commonly associated with conditions involving red blood cell fragmentation, such as hemolysis or microangiopathy.

Choice C rationale:

Schistocytes indicate hemolysis or microangiopathy.

Rationale: This statement is correct.

Schistocytes are fragmented red blood cells, and their presence on a peripheral blood smear is indicative of hemolysis (destruction of red blood cells) or microangiopathy (damage to small blood vessels)

This finding suggests that the patient may have an underlying condition leading to red blood cell destruction, which can be associated with thrombocytopenia.

Choice D rationale:

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 a more direct factor in bleeding risk.

Choice A rationale:

The presence of lymphadenopathy Lymphadenopathy refers to the enlargement of lymph nodes and is not a primary assessment finding to identify potential causes and types of thrombocytopenia.

While it may be relevant in some cases, it is not as prioritized as signs of infection or organ dysfunction.

Choice B rationale:

The patient's history of herbal supplements While the patient's history of herbal supplements is important to assess for potential causes of thrombocytopenia, it is not the most immediate assessment finding to prioritize.

Signs of infection or organ dysfunction are more crucial in the initial assessment as they may indicate acute and potentially life-threatening conditions.

Choice D rationale:

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 they can guide immediate intervention.

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.

Choice B rationale:

Administer plasma exchange therapy Administering plasma exchange therapy may be indicated in some cases of thrombocytopenia, but it is not the initial intervention when a client presents with petechiae, pallor, and weakness.

The primary concern in this situation is addressing active bleeding, which is best managed by applying pressure to bleeding sites and elevating the affected area.

Choice C rationale:

Monitor renal function and fluid balance While monitoring renal function and fluid balance is important in the overall care of a client with thrombocytopenia, it is not the immediate intervention when the client presents with symptoms of bleeding and weakness.

The priority is to stop the bleeding by applying pressure and elevating the affected area.

Choice D rationale:

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 symptom management.

Choice A rationale:

Administer platelet transfusions for life-threatening hemorrhage.

Platelet transfusions are typically administered in cases of severe thrombocytopenia where the risk of life-threatening hemorrhage is high.

However, it is not appropriate to administer platelet transfusions routinely or without a specific indication.

Therefore, this choice is not applicable in all cases of thrombocytopenia.

Choice B rationale:

Discontinue heparin immediately if signs of thrombosis are present.

In patients with thrombocytopenia, the use of heparin can increase the risk of bleeding.

If signs of thrombosis (clot formation) occur while a patient is on heparin, it is crucial to discontinue the medication promptly to prevent further clot formation.

This is a necessary intervention in such cases.

Choice C rationale:

Teach the patient to avoid NSAIDs, aspirin, and alcohol.

Patients with thrombocytopenia have a reduced number of platelets, which are essential for blood clotting.

NSAIDs (nonsteroidal anti-inflammatory drugs), aspirin, and alcohol can further increase the risk of bleeding by interfering with platelet function or causing irritation to the gastrointestinal tract.

Therefore, it is essential to educate patients to avoid these substances to minimize bleeding risks.

Choice D rationale:

Administer corticosteroids, IVIG, anti-D antibody, or rituximab as prescribed.

These treatments may be prescribed in specific cases of thrombocytopenia, depending on the underlying cause.

Corticosteroids can help reduce immune-mediated destruction of platelets, IVIG (intravenous immunoglobulin) can boost platelet levels, anti-D antibody is used in Rh-positive individuals with Rh-negative platelets, and rituximab may be prescribed for certain autoimmune causes of thrombocytopenia.

The administration of these medications is based on the patient's specific diagnosis and medical orders.

Choice E rationale:

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, signs of bleeding, and other relevant laboratory parameters would be more specific and valuable in assessing the effectiveness of treatment.

Choice A rationale:

Administering alternative anticoagulants.

Administering alternative anticoagulants is not the primary intervention for preventing or managing bleeding in a client with thrombocytopenia.

Anticoagulants may increase the risk of bleeding in such patients and are generally not indicated unless there is a specific medical reason to use them.

Choice B rationale:

Preparing the client for splenectomy.

Splenectomy is not typically performed as a preventive measure for bleeding in thrombocytopenic patients.

While splenectomy may be considered in some cases of immune thrombocytopenia, it is not the essential nursing intervention to prevent or manage bleeding in most clients with thrombocytopenia.

Choice C rationale:

Avoiding platelet transfusions.

Avoiding platelet transfusions is not a recommended intervention in clients with thrombocytopenia who are at risk of bleeding complications.

Platelet transfusions are often necessary to raise platelet levels and prevent or manage bleeding in these individuals.

Choice D rationale:

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 minimize bleeding.

It is a fundamental measure in the care of thrombocytopenic clients.

Choice A rationale:

Encourage the patient to consume NSAIDs for pain relief.

Encouraging the use of NSAIDs for pain relief is not appropriate for patients with thrombocytopenia.

NSAIDs can further increase the risk of bleeding due to their antiplatelet effects.

Therefore, it is crucial to educate patients to avoid NSAIDs.

Choice B rationale:

Teach the patient to avoid alcohol and aspirin.

This is a crucial part of patient education for those with thrombocytopenia.

Alcohol and aspirin can both increase the risk of bleeding, so advising patients to avoid them is essential to minimize bleeding risks.

Choice C rationale:

Suggest regular injections to stimulate platelet production.

While there are treatments available to stimulate platelet production, they are typically prescribed by a healthcare provider based on the patient's specific diagnosis and medical needs.

Suggesting regular injections without medical guidance is not appropriate.

Choice D rationale:

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 to undetected issues.