An 82-year-old client who sustained a head injury in a motor vehicle crash while on warfarin therapy is admitted for observation. The nurse is providing teaching regarding the client's diagnosis of a subdural hematoma. Which of the following statements by the client indicates an understanding of teaching?
"I developed a hematoma because an artery burst in my brain when my head hit the windshield."
"I developed a bleed in my brain because my platelets were too high."
"I developed a hematoma because I take a blood thinner and my head hit the windshield."
"I developed a hematoma because my bleeding times were too low and I hit my head."
The Correct Answer is C
A. A subdural hematoma is typically caused by venous bleeding, not arterial bleeding. An arterial rupture would more likely cause an epidural hematoma, which is not the case here.
B. High platelet counts are not commonly associated with the formation of subdural hematomas. Subdural hematomas are usually due to bleeding related to anticoagulant use or trauma.
C. Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
D. Low bleeding times are not a cause of hematomas. In fact, elevated bleeding times due to anticoagulant therapy would increase the risk of bleeding, not low bleeding times.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important for individuals with SLE, maintaining an overly cold environment can also trigger symptoms, as cold temperatures can lead to vasoconstriction and Raynaud's phenomenon, which is common in SLE patients.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is an essential component of managing SLE. This indicates that the client understands the importance of medication adherence in controlling the disease.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is a known exacerbating factor for SLE. This statement reflects the client's understanding of the need to reduce stress to prevent flare-ups.
D. Wearing protective clothing when going outside is important because UV light exposure can trigger SLE exacerbations. This shows that the client is aware of the need to protect their skin from sunlight.
Correct Answer is C
Explanation
A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.
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