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The nurse on the pediatric unit is caring for a patient with a diagnosis of hemophilia. The patient is a childâ??a 10-year-old boy. The nurse knows that a priority nursing diagnosis for this patient would be what?
- A. Hypothermia
- B. Diarrhea
- C. Ineffective coping
- D. Imbalanced nutrition
Correct Answer: C
Rationale: Most patients with hemophilia are diagnosed as children. They often require assistance in coping with the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea or imbalanced nutrition.
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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 patient's absolute neutrophil count (ANC) is 440/mm3. But the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient?
- A. Meticulous hand hygiene
- B. Timely administration of antibiotics
- C. Provision of a nutrient-dense diet
- D. Maintaining a sterile care environment
Correct Answer: A
Rationale: Providing care for a patient with neutropenia requires that the nurse adhere closely to standard precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care.
A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient?
- A. Packed red blood cells (PRBCs)
- B. Vitamin K
- C. Oral anticoagulants
- D. Heparin infusion
Correct Answer: A
Rationale: Patients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be ordered once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the patient's bleeding.
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.
A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patient's plan of care?
- A. Risk for disuse syndrome related to ineffective peripheral circulation
- B. Functional urinary incontinence related to urethral occlusion
- C. Ineffective tissue perfusion related to thrombosis
- D. Ineffective thermoregulation related to hypothalamic dysfunction
Correct Answer: C
Rationale: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.