Nokea
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply.
- A. Instruct the client to use a razor blade to shave.
- B. Avoid administering enemas to the client.
- C. Encourage participation in noncontact sports.
- D. Teach the client how to apply direct pressure if bleeding occurs.
- E. Explain the importance of not flossing the gums.
Correct Answer: B,C,D
Rationale: Avoiding enemas (B), noncontact sports (C), and teaching pressure (D) prevent bleeding in hemophilia. Razor blades (A) and avoiding flossing (E) increase bleeding risk.
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Which of the following assessment findings should alert the nurse that the elderly client should be evaluated for pernicious anemia?
- A. Clubbing of the nails
- B. Bloody stools
- C. Beefy-red tongue
- D. Enlarged lymph nodes
Correct Answer: C
Rationale: A beefy-red tongue is a classic symptom of pernicious anemia due to vitamin B12 deficiency.
The nurse teaches a coworker about the treatment for hemophilia. The nurse instructs that the treatment will likely include periodic self-administration of which component?
- A. Platelets
- B. Whole blood
- C. Factor concentrates
- D. Fresh frozen plasma
Correct Answer: C
Rationale: A. Platelets do not contain the deficient clotting factors. B. Although whole blood contains the deficient factors, periodic administration of factor concentrates are safer. C. A person with hemophilia A is deficient in factor VIII; hemophilia B, factor IX; and von Willebrand’s hemophilia, the von Willebrand’s factor and factor VIII. Recombinant forms of the factors are available for the client to self-administer intravenously at home. D. Although fresh frozen plasma contains the deficient factors, periodic administration of factor concentrates are safer.
The 33-year-old client diagnosed with Stage IV Hodgkin’s lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client?
- A. Instruct the client to continue scheduled screenings for cancer.
- B. Discuss the need for follow-up appointments every five (5) years.
- C. Teach the client that the cancer risk is the same as for the general population.
- D. Have the client talk with the family about funeral arrangements.
Correct Answer: A
Rationale: Post-remission Hodgkin’s requires ongoing cancer screenings (A) due to recurrence/second cancer risk. Follow-ups are more frequent than 5 years (B), risk remains elevated (C), and funeral plans (D) are premature.
The nurse writes a client problem of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Pace activities according to tolerance.
- B. Provide supplements high in iron and vitamins.
- C. Administer packed red blood cells.
- D. Monitor vital signs every four (4) hours.
Correct Answer: A
Rationale: Pacing activities (A) conserves energy in anemia-related activity intolerance. Supplements (B) and transfusions (C) are medical, and vitals (D) are routine, not primary.
The client is diagnosed with leukemia and has leukocytosis. Which laboratory value would the nurse expect to assess?
- A. An elevated hemoglobin.
- B. A decreased sedimentation rate.
- C. A decreased red cell distribution width.
- D. An elevated white blood cell count.
Correct Answer: D
Rationale: Leukocytosis in leukemia causes elevated WBCs (D). Hb (A) is low, ESR (B) is elevated, and RDW (C) is unrelated.