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Ati paediatrics benchmark exam
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Showing 10 questions, Sign in for moreA nurse is caring for a child who presents with a nosebleed (epistaxis). The nurse considers several interventions. For each potential intervention, specify if the potential intervention is expected or unexpected for the client.
Explanation
Choice A rationale
Applying direct pressure to the anterior nasal septum for at least 10 minutes is a standard first-line intervention for epistaxis. This action compresses the blood vessels, such as Kiesselbach's plexus, which are a common source of anterior nosebleeds. The sustained pressure promotes vasoconstriction and platelet plug formation, facilitating coagulation and cessation of the hemorrhage.
Choice B rationale
The administration of packed red blood cells is typically reserved for significant blood loss leading to symptomatic anemia or hemodynamic instability. A common nosebleed, while frightening, rarely results in a blood volume deficit severe enough to require transfusion. Transfusion carries risks like transfusion reactions, so it is not a routine measure for uncomplicated epistaxis. A normal hemoglobin range for children is typically around 11.5 to 15.5 g/dL.
Choice C rationale
Having the child tilt their head back is contraindicated for epistaxis. This action can cause blood to flow down the posterior pharynx, which can lead to aspiration or be swallowed. Swallowing blood can irritate the stomach, potentially causing nausea and vomiting, which may increase pressure and exacerbate the bleeding. The correct action is to have the child lean forward.
Choice D rationale
Topical antifibrinolytic agents, such as tranexamic acid, are medications that inhibit the breakdown of fibrin clots, thereby stabilizing the clot and promoting hemostasis. These agents can be applied directly to the site of bleeding via a soaked swab or nasal spray, providing a localized and effective treatment for persistent or recurrent epistaxis that doesn't respond to direct pressure.
Choice E rationale
Inserting cotton into the nostril without a hemostatic agent is generally not an effective intervention. Plain cotton does not provide the firm, consistent pressure required to compress the bleeding vessels. Furthermore, removing dry cotton can dislodge any forming clots, potentially reinitiating the hemorrhage. Nasal packing should only be performed with a medicated or specifically designed product.
Choice F rationale
Administering factor VIII is a specific treatment for individuals with hemophilia A, a congenital bleeding disorder characterized by a deficiency or defect of clotting factor VIII. Epistaxis is a common symptom of this condition, but administering this factor would be an unexpected intervention for a child without a known diagnosis of hemophilia. This is not a general treatment for nosebleeds. A normal range for factor VIII is 50%-150% of normal.
Choice G rationale
Applying ice or a cold compress to the bridge of the nose or forehead causes local vasoconstriction through a reflex arc. The cold temperature reduces blood flow to the area by constricting the blood vessels in the nasal mucosa, which helps to decrease the rate of bleeding. This is a common and effective adjunct therapy to direct pressure for managing epistaxis.
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Which of the following information should the nurse include?
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Which of the following findings should the nurse expect?
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Which of the following findings indicate that the immunization should be withheld?
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Which of the following interventions should the nurse include in the plan?
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Which of the following statements should the nurse include?
A nurse is planning care for an infant who has congenital talipes equinovarus.
Which of the following referrals should the nurse expect the provider to make?
A nurse is assessing a 4-year-old child following a surgical procedure.
Which of the following pain rating scales should the nurse use?
A nurse is educating a parent and child on the new diagnosis of type 1 diabetes mellitus.
Which of the following manifestations are associated with hypoglycemia?
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