Nokea
Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A?
- A. Epistaxis.
- B. Petechiae.
- C. Subcutaneous emphysema.
- D. Intermittent claudication.
Correct Answer: A
Rationale: Hemophilia A causes bleeding; epistaxis (A) is common. Petechiae (B) indicate thrombocytopenia, emphysema (C) is unrelated, and claudication (D) is vascular.
You may also like to solve these questions
The client is being admitted with folic acid deficiency anemia. Which would be the most appropriate referral?
- A. Alcoholics Anonymous.
- B. Leukemia Society of America.
- C. A hematologist.
- D. A social worker.
Correct Answer: C
Rationale: Folic acid deficiency anemia requires a hematologist (C) for evaluation/treatment. AA (A) is for alcoholism, Leukemia Society (B) is unrelated, and social work (D) is secondary.
The young adult, diagnosed with hemophilia A, is receiving a monthly scheduled dose of factor VIII cryoprecipitate. The client begins to cry during administration. Which response by the nurse is most appropriate?
- A. “Why are you crying? You seem afraid when I am administering the drug.”
- B. “Is it painful while I’m giving this IV push? If so, I can give it by infusion.”
- C. “I know this is uncomfortable for you; this only takes a few minutes to give.”
- D. “If you want to talk to me about what you are feeling, I am here to listen.”
Correct Answer: D
Rationale: A. Asking a “why” question challenges the client’s feelings. B. This response seeks information but is not most appropriate. It is unlikely that the initial response from an adult would not be crying if the administration of IV factor VIII cryoprecipitate by IV push were painful. C. This response ignores the client’s feelings and presumes that the nurse knows what initiated the client’s crying. D. The nurse is offering self, which is a therapeutic communication technique.
The client diagnosed with von Willebrand’s disease calls a clinic after experiencing hemarthrosis. The client states that factor concentrate is infusing. Which intervention should the nurse recommend now?
- A. “Take two 325-mg aspirin tablets every 4 hours for pain.”
- B. “Apply a cold pack to the area for 30 minutes every 1 to 2 hours.”
- C. “Come to the clinic; you need an infusion of fresh frozen plasma.”
- D. “If wearing a splint, remove it to avoid compartment syndrome.”
Correct Answer: B
Rationale: A. Aspirin (Ecotrin) and NSAIDs are contraindicated because they interfere with platelet aggregation. B. Hemarthrosis is bleeding into the joint. The pressure of the ice pack and cold will reduce the bleeding and swelling. The ice pack should be covered with a cloth. C. The client and family are usually taught how to administer factor concentrates at home at the first sign of bleeding. D. The splint should be left on initially to control bleeding. The client should be instructed on how to assess for adequate tissue perfusion.
The client is diagnosed with non-Hodgkin’s lymphoma. Which nursing concept should the nurse identify as priority?
- A. Immunity.
- B. Grieving.
- C. Perfusion.
- D. Clotting.
Correct Answer: A
Rationale: NHL impairs immunity (A) via lymph node dysfunction, increasing infection risk, a priority. Grieving (B), perfusion (C), and clotting (D) are secondary.
A child who has hemophilia is admitted to the hospital with a swollen knee joint. He is complaining of severe pain. What is the priority of nursing care for this child upon admission?
- A. Maintain joint function
- B. Use a bed cradle
- C. Administer aspirin as needed for pain
- D. Encourage fluids
Correct Answer: B
Rationale: Using a bed cradle reduces pressure on the swollen, painful joint, prioritizing pain relief and comfort during a bleeding episode.