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    NU335 proctored exam(adult healthmed surg exam (renal) exemplify

    Which sign would the nurse expect to assess in the patient diagnosed with idiopathic thrombocytopenic purpura (ITP)?

    Explanation & Rationale

    A. Capillary refill less than three (3) seconds: A normal capillary refill indicates adequate peripheral perfusion and is not a typical finding associated with idiopathic thrombocytopenic purpura (ITP), which primarily affects platelet count and bleeding tendencies rather than perfusion. B. Pulse oximeter reading of 95%: Oxygen saturation reflects respiratory function and is generally unaffected in ITP. This reading does not correlate with the hematologic manifestations of the disorder. C. An enlarged spleen: Splenomegaly is more characteristic of secondary causes of thrombocytopenia, such as certain infections or hematologic malignancies. In classic ITP, the spleen is usually normal in size. D. Petechiae on the anterior chest, arms, and neck: Petechiae are small, pinpoint hemorrhages resulting from platelet deficiency and are a hallmark sign of ITP. They appear on areas prone to pressure or trauma and indicate the patient’s increased risk for bleeding due to thrombocytopenia.

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