The nurse is assessing a post-op thyroidectomy patient for bleeding. Which finding would indicate bleeding at the surgical site?
Complaints of pain at the incision
Increased blood pressure
Decreased white blood cell count
Presence of blood on the pillow behind the patient
The Correct Answer is D
A. While pain can occur post-operatively and may be a sign of complications, it is not a direct indicator of bleeding. Pain can result from normal healing, surgical trauma, or other complications, but by itself, it does not specifically point to bleeding at the surgical site.
B. An increased blood pressure might not necessarily indicate bleeding. In some cases, blood pressure may increase due to pain, anxiety, or other factors. However, a significant drop in blood pressure would be more indicative of bleeding, especially in conjunction with other symptoms.
C. A decreased white blood cell count (leukopenia) is not typically associated with bleeding at the surgical site. In fact, following surgery, one might expect the white blood cell count to be normal or slightly elevated due to the body’s response to surgery.
D. This finding is indicative of bleeding at the surgical site. Blood on the pillow would suggest that there is active bleeding that has escaped from the surgical site, which is a significant concern that requires immediate assessment and intervention.
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Related Questions
Correct Answer is C
Explanation
A. This intervention can be appropriate since a very low platelet count increases the risk of bleeding, including gastrointestinal bleeding. However, this action alone does not directly address the immediate risks associated with the low platelet count.
B. While hydration is important for overall health, this intervention does not specifically address the risks associated with a low platelet count. Additionally, excessive fluid intake may not be appropriate for all patients, especially if there are underlying kidney issues or fluid restrictions.
C. Clients with AML and low platelet counts are at increased risk for infections and may develop febrile neutropenia. Monitoring temperature every four hours can help detect early signs of infection, allowing for timely intervention.
D. While maintaining oral hygiene is important, especially in patients undergoing chemotherapy, this intervention may not be the most critical action based on the acute concern of a very low platelet count. However, it is important to note that patients with low platelet counts may also experience bleeding from the gums, making gentle oral care essential.
Correct Answer is C
Explanation
A. Many women diagnosed with ovarian cancer are indeed older, but the presence of other health problems is not a primary factor in explaining the high death rates. The key issue is more related to late- stage diagnosis rather than age alone.
B. While some ovarian cancer cells can develop resistance to treatment, it is not universally true for all cases. The high mortality rate is more often due to the late stage at which the cancer is diagnosed rather than inherent resistance to treatment. Thus, this option does not fully explain the high death rates.
C. Ovarian cancer often presents with vague symptoms that can be easily overlooked in the early stages, such as bloating, abdominal discomfort, or changes in bowel habits. As a result, many women do not receive a diagnosis until the cancer has progressed to a more advanced stage, contributing significantly to the high mortality rates associated with the disease.
D. While it is true that the ovaries are located deep in the pelvis, the main treatment for ovarian cancer typically involves surgery and chemotherapy rather than radiation therapy. Radiation is not a primary treatment for this cancer type, and this statement does not accurately reflect why the death rates are high.
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