A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?
Have the client gently blow clots from his nose every 5 min
Instruct the client to sit with his head hyperextended
Apply ice compresses to the back of the client’s neck
Pinch the soft portion of the client’s nose for 10 min
The Correct Answer is D
Choice A reason: Having the client gently blow clots from his nose every 5 min is an incorrect action, because it can increase the bleeding and trauma to the nasal mucosa. The client should avoid blowing or picking his nose.
Choice B reason: Instructing the client to sit with his head hyperextended is an incorrect action, because it can cause the blood to drain into the throat and increase the risk of aspiration or vomiting. The client should sit with his head tilted forward.
Choice C reason: Applying ice compresses to the back of the client’s neck is an incorrect action, because it has no effect on the bleeding site. The nurse should apply ice compresses to the bridge of the nose or the cheeks to constrict the blood vessels and reduce the bleeding.
Choice D reason: Pinching the soft portion of the client’s nose for 10 min is a correct action, because it applies direct pressure to the bleeding site and allows clot formation. The nurse should instruct the client to breathe through his mouth and avoid swallowing the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is a vague and unhelpful response, because it does not provide any information or reassurance to the client who has a new diagnosis of MS. The nurse should explain the general course of MS and the possible variations among clients.
Choice B reason: This is a sympathetic but incomplete response, because it does not address the client's question or provide any information about the course of MS. The nurse should acknowledge the client's feelings and provide factual and realistic information.
Choice C reason: This is the best response, because it provides accurate and relevant information about the course of MS, which is a chronic and progressive disease that affects the central nervous system. MS can cause acute episodes of neurological symptoms, such as vision loss, numbness, weakness, or fatigue, which are followed by periods of remission, when the symptoms improve or disappear. The length and frequency of the episodes and remissions can vary among clients.
Choice D reason: This is a dismissive and unrealistic response, because it does not answer the client's question or respect the client's right to know about the course of MS. The nurse should not avoid the client's concerns or minimize the impact of the diagnosis. The nurse should help the client cope with the uncertainty and plan for the future.
Correct Answer is A
Explanation
Choice A reason: This is the best action, because compression stockings can help improve the blood flow and prevent the formation of new clots in the veins of the legs. Compression stockings can also reduce the swelling, pain, and inflammation caused by thrombophlebitis.
Choice B reason: This is an incorrect action, because cold compresses can cause vasoconstriction and worsen the blood flow and the clotting process in the affected vein. Cold compresses can also increase the discomfort and numbness of the extremity.
Choice C reason: This is an incorrect and dangerous action, because gently massaging the area can dislodge the clot and cause it to travel to the lungs, heart, or brain, resulting in a life-threatening complication, such as pulmonary embolism, myocardial infarction, or stroke.
Choice D reason: This is an incorrect and misleading statement, because heparin is not prescribed to dissolve the thrombus, but to prevent the growth and extension of the existing clot and the formation of new clots. Heparin is an anticoagulant that inhibits the clotting factors in the blood, but does not break down the clot. The body's own enzymes, such as plasmin, are responsible for dissolving the clot.
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