A nurse is teaching a client with newly diagnosed hemophilia about home care practices. What statements by the client indicate that teaching has been effective? Select all that apply.
“I will use a soft toothbrush to decrease bleeding from my gums.”.
“If I get a headache, I will take ibuprofen instead of aspirin.”.
“I will report excessive bleeding to my provider and use precautions to protect my head and joints.”.
“I need clotting factor treatments for the rest of my life if a bleed occurs.”.
“I may experience warm, painful joints and should apply heat if that occurs.”.
Correct Answer : A,C
Choice A is correct because using a soft toothbrush can decrease the risk of bleeding from the gums, which is a common site of bleeding for people with hemophilia.
Choice C is correct because reporting excessive bleeding to the provider and using precautions to protect the head and joints are important aspects of home care for hemophilia.
Choice B is wrong because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can interfere with platelet function and increase bleeding tendency. People with hemophilia should avoid NSAIDs and use acetaminophen instead for pain relief.
Choice D is wrong because clotting factor treatments are not only needed when a bleed occurs but also as a preventive measure to reduce the frequency and severity of bleeding episodes. People with severe hemophilia need regular clotting factor replacement therapy for the rest of their lives.
Choice E is wrong because warm, painful joints are signs of joint bleeding, which is a serious complication of hemophilia that can lead to permanent joint damage.
People with hemophilia should not apply heat to their joints, but rather use ice packs, compression, elevation and rest to reduce swelling and pain. They should also seek medical attention and receive clotting factor replacement therapy as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy
treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.
According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).
Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.
Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.
Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.
Correct Answer is D
Explanation
Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.
Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.
Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.
Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.
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