A client with hemophilia is admitted to the hospital with an acute joint bleed. What is the nurse's priority intervention for managing joint bleeding in this client?
Apply a warm compress to the affected joint.
Administer prescribed clotting factor replacement therapy.
Elevate the affected joint to reduce swelling.
Encourage active range of motion exercises.
The Correct Answer is B
A) Incorrect. Applying a warm compress may promote vasodilation and increase bleeding in the joint. It is not recommended for managing joint bleeding in a client with hemophilia.
B) Correct. The priority intervention for managing joint bleeding in a client with hemophilia is to administer prescribed clotting factor replacement therapy to promote clot formation and stop the bleeding.
C) Incorrect. Elevating the affected joint can help reduce swelling, but it is not the priority intervention when the client is experiencing an acute joint bleed.
D) Incorrect. Encouraging active range of motion exercises can worsen joint bleeding and is contraindicated in a client with acute joint bleeding due to hemophilia.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Swelling and bruising around the wound are common signs of external bleeding and do not directly indicate internal bleeding.
B) Correct. Cool and pale skin in the extremities may be indicative of vasoconstriction and reduced blood flow, which can occur in response to internal bleeding.
C) Incorrect. Blood oozing from the wound site is a typical sign of external bleeding and does not necessarily indicate internal bleeding.
D) Incorrect. Visible blood clot formation at the wound site is a normal part of the body's hemostatic response to control external bleeding and does not directly suggest internal bleeding.
Correct Answer is A
Explanation
A) Correct. In liver cirrhosis, the damaged liver may sequester platelets, leading to a decreased platelet count. However, an elevated platelet count (thrombocytosis) can occur as a compensatory response to decreased liver function and is a sign of an increased risk of hemorrhage due to poor clot formation.
B) Incorrect. Low prothrombin time (PT) indicates faster clotting and is not associated with an increased risk of hemorrhage.
C) Incorrect. Decreased ammonia levels are a positive finding in liver cirrhosis, as elevated ammonia levels are harmful to the brain.
D) Incorrect. Elevated liver enzymes are indicative of liver damage, but they do not directly impact the client's risk of hemorrhage.
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