Nokea
A nurse is a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which of the following?
- A. Housing the resident in a private room
- B. Implementing a passive ROM program to compensate for activity limitation
- C. Implementing of a plan for fall prevention
- D. Providing the patient with a high-fiber diet
Correct Answer: C
Rationale: To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase fiber intake.
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A patient with Von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure?
- A. The patient should not undergo the normal bowel cleansing protocol prior to the procedure.
- B. The patient should receive a unit of fresh-frozen plasma 48 hours before the procedure.
- C. The patient should be admitted to the surgical unit on the day before the procedure.
- D. The patient should be given necessary clotting factors before the procedure.
Correct Answer: D
Rationale: A goal of treating vWD is to replace the deficient protein (e.g., vWF or factor VIII) prior to an invasive procedure to prevent subsequent bleeding. Bowel cleansing is not contraindicated and FFP does not reduce the patient's risk of bleeding. There may or may not be a need for preprocedure hospital admission.
A nurse is caring for a patient who has sickle cell anemia and the nurses assessment reveals the possibility of substance abuse. What is the nurses most appropriate action?
- A. Encourage the patient to rely on complementary and alternative therapies.
- B. Encourage the patient to seek care from a single provider for pain relief.
- C. Teach the patient to accept chronic pain as an inevitable aspect of the disease.
- D. Limit the reporting of emergency department visits to the primary health care provider.
Correct Answer: B
Rationale: The patient should be encouraged to use a single primary health care provider to address health care concerns. Emergency department visits should be reported to the primary health care provider to achieve optimal management of the disease. It would be inappropriate to teach the patient to simply accept his or her pain. Complementary therapies are usually insufficient to fully address pain in sickle cell disease.
A patients blood work reveals a platelet level of 17,000/mm3. When inspecting the patients integumentary system, what finding would be most consistent with this platelet level?
- A. Dermatitis
- B. Petechiae
- C. Urticaria
- D. Alopecia
Correct Answer: B
Rationale: When the platelet count drops to less than 20,000/mm?³, petechiae can appear. Low platelet levels do not normally result in dermatitis, urticaria (hives), or alopecia (hair loss).
A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function?
- A. Antihypertensives
- B. Penicillins
- C. Sulfa-containing medications
- D. Aspirin
- E. NSAIDs
Correct Answer: C,D,E
Rationale: The nurse must be alert for sulfa-containing medications and others that alter platelet function (e.g., aspirin-based or other NSAIDs). Antihypertensive drugs and the penicillins do not alter platelet function.
A patient is admitted to the diagnosis of pernicious anemia. The nurse should prepare to administer which of the following medications?
- A. Folic acid
- B. Vitamin B12
- C. Lactulose
- D. Magnesium sulfate
Correct Answer: B
Rationale: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia.