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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Assessing current anticoagulant use is a priority because t-PA (tissue plasminogen activator) can increase the risk of bleeding, especially if the client has been on anticoagulant medications. It is crucial to determine if there are any contraindications or increased risks for bleeding.
B. While blood pressure control is important, it is secondary to understanding the client's anticoagulant use as it directly affects the safety of t-PA administration.
C. A complete neurologic assessment is important but comes after ensuring there are no contraindications such as recent anticoagulant use that could affect the safety of t-PA.
D. Current treatment for peptic ulcer disease may be relevant for bleeding risks but is not as immediately critical as reviewing anticoagulant use for t-PA safety.

A. Performing hand hygiene before, during, and after direct contact with the client B. Changing the client's bed linens each day C. Controlling the client's blood glucose level D. Placing the client in a room with positive-pressure airflow

Correct Answer is A

Explanation

A. Performing hand hygiene before, during, and after direct contact with the client is the most effective strategy for preventing the transmission of infections. Hand hygiene interrupts the transmission of pathogens and is a cornerstone of infection control practices.
B. Changing the client's bed linens each day is a standard practice for maintaining cleanliness but does not specifically prevent infection transmission. The primary goal of infection control is to reduce pathogen transmission rather than just maintaining general cleanliness.
C. Controlling the client's blood glucose level is important for overall health and wound healing but does not directly prevent infection transmission. It is not an infection control strategy.
D. Placing the client in a room with positive-pressure airflow is used to protect immunocompromised patients from infections by preventing outside air from entering the room. However, it is not appropriate for preventing the transmission of an infection from a client to others.

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Naxlex Comprehensive Predictor Exams

A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

Correct Answer is A

Explanation

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

Correct Answer is A

Explanation

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