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
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.
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Correct Answer is C
Explanation
A) Incorrect. Hemophilia does not increase the risk of forming blood clots. In fact, it causes difficulty in forming blood clots, leading to an increased risk of bleeding and hemorrhage.
B) Incorrect. Platelet count is not directly affected in hemophilia. It is primarily a disorder of clotting factors.
C) Correct. Hemophilia is a genetic disorder characterized by a deficiency or absence of specific clotting factors, which impairs the blood's ability to clot properly.
D) Incorrect. Hemophilia does not affect the number of red blood cells, which are responsible for oxygen transport.
Correct Answer is A
Explanation
A) Correct. Bone marrow aspiration involves the removal of a small sample of bone marrow from the hip bone to assess the production of blood cells and identify potential causes of bleeding disorders.
B) Incorrect. The statement describes an esophagogastroduodenoscopy (EGD), which is not the procedure scheduled for this client.
C) Incorrect. Monitoring blood pressure and heart rate is essential during any procedure, but it is not specific to bone marrow aspiration.
D) Incorrect. An ultrasound is not relevant to a bone marrow aspiration procedure and is not used to assess bleeding disorders. It is typically used for imaging soft tissues and organs.
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