A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia A. Which of the following instructions should the nurse include?
Administer aspirin for pain.
Place knee pads on the child.
Perform passive range-of-motion exercises following an acute episode.
Use a firm-bristled toothbrush for dental care.
The Correct Answer is B
A. Administer aspirin for pain. Aspirin increases the risk of bleeding and is contraindicated in clients with hemophilia. Acetaminophen is recommended instead.
B. Place knee pads on the child. Protective gear like knee pads can help prevent joint injuries, which are common in toddlers with hemophilia.
C. Perform passive range-of-motion exercises following an acute episode. Active range-of-motion exercises are preferred after an acute episode to prevent joint damage. Passive exercises can exacerbate bleeding.
D. Use a firm-bristled toothbrush for dental care. A soft-bristled toothbrush should be used to minimize gum bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition Most Likely Experiencing: Bronchiolitis
The infant's symptoms—fever, cough, nasal congestion, wheezing, nasal flaring, intercostal retractions, and difficulty feeding—are characteristic of bronchiolitis, commonly caused by RSV in infants.
Actions to Take:
- Administer Oxygen via nasal cannula: The infant's low oxygen saturation (88% on room air) and respiratory distress (nasal flaring, retractions) indicate the need for supplemental oxygen to ensure adequate oxygenation and reduce respiratory distress.
- Suction nares with a bulb aspirator: Suctioning the infant’s nasal passages helps clear mucus and improve breathing. Infants with RSV often have significant nasal congestion that can impair feeding and breathing, so clearing the airways is crucial for respiratory management.
Parameters to Monitor:
- Oxygen saturation via continuous pulse oximetry: Monitoring oxygen saturation provides critical information on the infant’s respiratory status and helps assess the effectiveness of oxygen therapy.
- Respiratory effort and breath sounds: The infant is showing signs of increased respiratory effort (e.g., nasal flaring, intercostal retractions) and abnormal breath sounds (e.g., wheezes). Monitoring these parameters helps assess the severity of respiratory distress and guides further interventions.
Correct Answer is B
Explanation
A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.
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