A nurse is developing a plan of care for a 4-year-old child who has hemophilia and is experiencing acute hemarthrosis. Which of the following interventions should the nurse include in the plan?
Have the child perform passive range-of-motion exercises.
Administer aspirin as needed for pain.
Place ice packs on the affected joints.
Position the lower extremities below the level of the heart.
The Correct Answer is C
A. Have the child perform passive range-of-motion exercises: This is not recommended during acute hemarthrosis in hemophilia because it can further exacerbate bleeding and increase joint damage. Passive range-of-motion exercises should be avoided until bleeding has been adequately controlled.
B. Administer aspirin as needed for pain: Aspirin is not recommended for pain management in hemophilia due to its antiplatelet effects, which can further prolong bleeding. Instead, acetaminophen (Tylenol) or other nonsteroidal anti-inflammatory drugs (NSAIDs) that do not affect clotting mechanisms may be used for pain relief.
C. Place ice packs on the affected joints: This is a recommended intervention. Ice packs can help reduce inflammation and swelling in the affected joints, providing pain relief and potentially slowing down bleeding. However, it's important to ensure that the ice pack is wrapped in a cloth or towel to prevent direct contact with the skin, which could cause tissue damage.
D. Position the lower extremities below the level of the heart: This is not recommended. Elevating the affected extremity above the level of the heart can help reduce swelling and minimize bleeding. Placing the lower extremities below the level of the heart could potentially increase bleeding.
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Related Questions
Correct Answer is B
Explanation
A. The infant does not exhibit fear of strangers.
The infant does not exhibit fear of strangers is not a finding that the nurse should report to the provider, as this is a normal social behavior for a 6-month-old infant. Infants usually develop stranger anxiety between 8 and 12 months of age, when they become more aware of their surroundings and attachment figures.
B. The infant does not roll over from his abdomen to his back.
By 6 months of age, most infants can roll over in both directions— from their abdomen to their back and vice versa. The inability to roll over from abdomen to back may indicate a delay in gross motor skills development. This finding should be reported to the healthcare provider for further evaluation.
C. The infant does not pick up objects from the floor with his fingers.
By 6 months of age, infants typically begin to develop the ability to grasp and pick up objects using their fingers. This milestone is part of fine motor skills development. The inability to pick up objects from the floor with fingers may indicate a delay in fine motor skills and should be reported to the provider for further assessment.
D. The infant does not sit on the floor unsupported.
By 6 months of age, infants typically begin to develop the ability to sit unsupported for short periods. While some variability exists in when infants achieve this milestone, the inability to sit unsupported at 6 months may indicate a delay in gross motor skills development. This finding should be reported to the provider for further evaluation.
Correct Answer is A
Explanation
A. Pull the pinna down and back: This technique is appropriate for administering otic drops to an infant or young child. By gently pulling the pinna (outer ear) down and back, it straightens the ear canal, allowing the drops to enter more effectively.
B. Insert the dropper into the ear canal: This option is incorrect. It is essential not to insert the dropper directly into the ear canal, especially in young children, to prevent injury to the ear drum or ear canal.
C. Administer the ear drops at 5.5°C (42°F): The temperature at which the ear drops are administered is not typically specified in practice. Room temperature drops are generally recommended for patient comfort, but they do not need to be at a specific temperature.
D. Massage the area behind the ear: Massaging the area behind the ear after administering otic drops can help distribute the medication within the ear canal. However, it is essential to follow specific instructions provided by the healthcare provider regarding post-administration care.
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