A nurse receives a call from a parent of a child who has von Willebrand disease and has had a nosebleed. Which of the following instructions should the nurse give to the parent?
"Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes."
"Apply ice at the base of the nose for 5 min and then check for bleeding.
"Place your child in a supine position with a pillow under her back."
"Place your child in a sitting position with her head tilted back
The Correct Answer is A
For a child with von Willebrand disease experiencing a nosebleed, the nurse should instruct the parent to have the child sit with their head tilted forward slightly (not backward) to prevent blood from flowing down the throat. Applying direct pressure to the nostrils with fingers or using a clean cloth for about 10 minutes will help stop the bleeding.
Option B (applying ice at the base of the nose) is not recommended because ice can cause vasoconstriction, potentially prolonging bleeding in individuals with bleeding disorders.
Option C (placing the child in a supine position with a pillow under the back) is also not recommended, as this can lead to blood flowing down the throat, increasing the risk of aspiration.
Option D (placing the child in a sitting position with her head tilted back) should be avoided as it can lead to blood flowing into the throat and potentially being swallowed or aspirated. This position is generally discouraged for nosebleeds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should recommend bananas as a safe food choice for a 2-year-old child. Bananas are soft and easy to chew, making them safe for young children. They do not pose a choking hazard, unlike grapes, raw carrots, or celery.
Option B (Grapes) can be a choking hazard for young children, especially if they are not cut into small pieces or are given whole.
Option C (Raw carrots) and Option D (Celery) are hard and crunchy, and they require more chewing, which may not be safe for a 2-year-old child who is still developing their chewing and swallowing abilities.
As a general guideline, when selecting foods for young children, it is essential to choose soft, easily chewable, and non-choking hazard options to promote safe eating and reduce the risk of choking incidents.
Correct Answer is C
Explanation
In an infant with a history of vomiting and fever, body weight is the most reliable indicator of fluid loss. Monitoring the infant's weight over time can help assess the degree of dehydration and guide the appropriate fluid replacement therapy. A significant decrease in body weight suggests significant fluid loss.
Option A: Skin integrity is important to assess for signs of dehydration, but it is not as reliable as body weight in determining the extent of fluid loss.
Option B: Respiratory rate can be affected by various factors and is not a direct indicator of fluid loss.
Option D: Blood pressure is not the most reliable indicator of fluid loss in an infant with dehydration. In severe cases of dehydration, blood pressure can drop, but it is not as sensitive as body weight in assessing the extent of fluid loss.
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