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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Administer IV antibiotics: While urgent, antibiotics can be administered after precautions are in place to ensure safety.
B. Monitor vital signs: Important but not the first action. Vital signs can be monitored after precautions are initiated.
C. Encourage oral fluids: Incorrect because IV fluids are usually required due to the severity of the illness and risk of shock.
D. Initiate droplet precautions. Protecting others from transmission is the highest priority in managing bacterial meningitis, a highly contagious condition.

A. Face, legs, activity, cry, consolability (FLACC) scale B. Oucher scale C. FACES scale D. Visual analog scale (VAS)

Correct Answer is A

Explanation

A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.

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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?

Nursing Test Bank

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