A nurse is caring for a client with hemophilia.
The client reports pain, swelling, and reduced range of motion in their joints.
Which of the following statements by the nurse is appropriate?
"It's just a minor issue, and the pain will go away on its own.”
"Let's apply ice to the affected joint to reduce the swelling.”
"I'll assess your joint and provide pain management as needed.”
"You should perform strenuous exercises to improve joint mobility.”
The Correct Answer is C
Choice A rationale:
"It's just a minor issue, and the pain will go away on its own." This statement is not appropriate because joint pain, swelling, and reduced range of motion in a client with hemophilia, known as hemarthrosis, can lead to long-term joint damage and disability if not properly managed.
Downplaying the issue is not in the best interest of the client and may lead to inadequate care.
Choice B rationale:
"Let's apply ice to the affected joint to reduce the swelling." While applying ice to an inflamed joint can help reduce swelling in some cases, it may not be the best immediate approach for a client with hemophilia.
Ice application should be done with caution, as it can potentially worsen bleeding in individuals with hemophilia.
The primary focus should be on assessing the severity of the bleeding, providing appropriate pain management, and consulting with a healthcare provider.
Choice C rationale:
"I'll assess your joint and provide pain management as needed." This is the most appropriate response.
The nurse should assess the client's joint for signs of hemarthrosis, such as swelling, warmth, and reduced range of motion.
Prompt assessment allows for early intervention to manage the bleeding and alleviate pain.
Providing pain management as needed, which may include analgesic medications, is essential to improve the client's comfort and prevent further complications.
Choice D rationale:
"You should perform strenuous exercises to improve joint mobility." Encouraging strenuous exercises in a client with hemophilia who is already experiencing joint pain and swelling is not advisable.
Strenuous exercise can exacerbate bleeding and joint damage.
Instead, the focus should be on gentle range-of-motion exercises and physical therapy, guided by a healthcare provider, to improve joint mobility without increasing the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"It's essential to limit your fluid intake to prevent further bleeding." Rationale: This statement is incorrect.
Limiting fluid intake will not prevent bleeding in a client with hemophilia.
In fact, maintaining adequate hydration is important to prevent complications and maintain overall health.
Choice B rationale:
"Let's administer aspirin to help with the pain and swelling." Rationale: This statement is also incorrect.
Aspirin is not recommended for individuals with hemophilia as it can further increase the risk of bleeding due to its antiplatelet effects.
Administering aspirin would be contraindicated in this case.
Choice C rationale:
"I'll monitor your condition closely and provide appropriate treatments." Rationale: This is the correct statement.
For a client with hemophilia experiencing bleeding into muscles, soft tissues, and the gastrointestinal tract, close monitoring and appropriate treatments are essential.
This may include administering clotting factor concentrates, pain management, and supportive care.
Choice D rationale:
"This bleeding is normal and should resolve on its own." Rationale: This statement is incorrect and potentially dangerous.
Bleeding in a client with hemophilia is not normal and should not be left untreated.
Without intervention, it can lead to severe complications and even life-threatening situations.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Family history of bleeding disorders.
Rationale: In the assessment of a client suspected of having hemophilia, it is essential to inquire about a family history of bleeding disorders because hemophilia is a genetic disorder, and a positive family history can be a strong indicator.
Choice B rationale:
Recent traumatic injuries.
Rationale: Inquiring about recent traumatic injuries is important because individuals with hemophilia are at increased risk of bleeding following injuries.
Knowing about recent trauma helps assess the risk of bleeding episodes.
Choice C rationale:
Medications affecting coagulation.
Rationale: It is crucial to inquire about medications that can affect coagulation, such as anticoagulants or antiplatelet agents, as these medications can increase the risk of bleeding in individuals with hemophilia.
Choice D rationale:
Allergies to latex products.
Rationale: While allergies to latex products should be assessed for safety reasons, it is not directly related to the diagnosis of hemophilia.
This information is important for overall patient safety but is not a specific factor in diagnosing hemophilia.
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