The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?

Have the patient take a number and stay in the waiting area.

Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.

Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room.

Palpate the suspected area of bleeding for tenderness and edema.

Answer and Explanation

The Correct Answer is B

A. Have the patient take a number and stay in the waiting area. Delaying care could lead to worsening of a potentially life-threatening bleeding episode. Hemophilia patients should be assessed promptly.

B. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. Hemophilia patients are at risk of internal bleeding, which may not always be visible externally. Rapid assessment is essential to prevent complications from internal bleeding.

C. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. X-rays may not immediately detect bleeding in soft tissues. The physician should evaluate the patient first.

D. Palpate the suspected area of bleeding for tenderness and edema. Palpating could worsen bleeding or cause pain, and the nurse should focus on ensuring the patient is seen promptly by the physician.

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Correct Answer is C

Explanation

A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.

B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.

C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.

D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.

A. Reported pain B. Bleeding C. Temperature D. Bruising E. WBC count

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,C"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Reported pain

Leukemia: Possible, as bone pain can occur due to marrow involvement.
Sickle Cell Anemia: Yes, common due to vaso-occlusive crises.
Hemophilia: No, hemophilia typically causes bleeding rather than pain from blood cell abnormalities.

Bleeding

Leukemia: Yes, due to thrombocytopenia.
Sickle Cell Anemia: No, bleeding is not typical in sickle cell crises.
Hemophilia: Yes, hemophilia is a bleeding disorder due to a clotting factor deficiency.

Temperature

Leukemia: Yes, fever can indicate infection due to immunosuppression.
Sickle Cell Anemia: Yes, fever can be a sign of infection during crises.
Hemophilia: No, hemophilia does not cause fever unless there is an infection.

Bruising

Leukemia: Yes, thrombocytopenia can lead to easy bruising.
Sickle Cell Anemia: No, bruising is not typical in sickle cell crises.
Hemophilia: Yes, due to a clotting factor deficiency, easy bruising is common.

WBC count

Leukemia: Yes, often elevated due to immature or abnormal white cells.
Sickle Cell Anemia: No, WBC count is usually normal unless there is an infection.
Hemophilia: No, WBC count is typically normal in hemophilia.

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The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,C"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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