A nurse is caring for a client with a suspected bleeding disorder. Which nursing assessment is most essential to identify potential bleeding sources?

Neurological assessment

Skin integrity assessment

Abdominal assessment

Respiratory assessment

Answer and Explanation

The Correct Answer is B

A) Incorrect. A neurological assessment is important to evaluate the client's central nervous system function, but it is not directly related to identifying bleeding sources.

B) Correct. A skin integrity assessment is essential to identify potential external bleeding sources, such as cuts, bruises, or petechiae, which may indicate underlying bleeding disorders.

C) Incorrect. While an abdominal assessment is crucial in identifying internal bleeding in the abdominal area, it is not the most essential assessment to identify bleeding sources overall.

D) Incorrect. A respiratory assessment is important for assessing oxygenation and respiratory status, but it is not the primary assessment to identify bleeding sources.

Questions

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Correct Answer is C

Explanation

A) Correct. Avoiding herbal supplements is important as some herbs can interact with anticoagulant medications and affect their effectiveness.

B) Correct. Notifying the healthcare provider about unusual

bruising is essential, as it may indicate potential bleeding complications associated with anticoagulant therapy.

C) Incorrect. Taking aspirin while on anticoagulant therapy can increase the risk of bleeding and is not recommended without medical guidance.

D) Correct. Carrying a medical alert card indicating anticoagulant use is crucial to inform healthcare providers about the client's medication regimen in case of emergency.

Questions

A. Elevated platelet count. B. Low prothrombin time (PT). C. Decreased ammonia levels. D. Elevated liver enzymes.

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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A nurse is caring for a client with a suspected bleeding disorder. Which nursing assessment is most essential to identify potential bleeding sources?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving anticoagulant therapy to prevent blood clots. Which statement by the client indicates a need for further education about the medication?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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