Author Question: Which nursing diagnosis should the nurse identify as being the most appropriate for a child with ... (Read 26 times)

jlmhmf · **on:** Jun 27, 2018

Which nursing diagnosis should the nurse identify as being the most appropriate for a child with idiopathic thrombocytopenic purpura?

A) Risk for infection related to abnormal immune system
B) Risk for bleeding related to insufficient platelet formation
C) Risk for altered urinary elimination related to kidney impairment
D) Ineffective breathing pattern related to decreased white blood count

Question 2

While receiving a transfusion of packed red blood cells, a school-age child begins to experience itchy skin, hives, and wheezes. What should the nurse do first for this child?

A) Stop the transfusion.
B) Obtain a blood culture.
C) Slow the transfusion rate.
D) Provide a diuretic as prescribed.

chjcharjto14 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

B
Feedback:
Idiopathic thrombocytopenic purpura (ITP) is the result of a decrease in the number of circulating platelets in the presence of adequate megakaryocytes, which are precursors to platelets. Because bleeding can occur with this disease process, the diagnosis most appropriate for the patient at this time is risk for bleeding related to insufficient platelet formation. Reduced numbers of platelets would not increase the patient's risk for infection. Reduced numbers of platelets does not increase the patient's risk for renal impairment. Reduced risk of platelets will not lead to an ineffective breathing pattern.

Answer to Question 2

A
Feedback:
Itchy skin, hives, and wheezes while receiving a blood transfusion indicate an allergic reaction to the blood proteins. The nurse should stop the infusion. This will be temporary because after the child receives oxygen and an antihistamine, the transfusion will be resumed. Blood cultures are indicated if the child experiences an increase in body temperature. Slowing the transfusion rate will not reduce the patient's symptoms. A diuretic would be indicated if the child demonstrates shortness of breath and an increased pulse rate.