A patient receiving heparin therapy develops bruising and bleeding gums. What should the nurse suspect and what is the appropriate action?
Suspect an allergic reaction and administer antihistamines.
Suspect a bleeding complication and notify the healthcare provider.
Suspect a hypersensitivity reaction and discontinue the heparin immediately.
Suspect an infection and initiate antibiotic therapy.
The Correct Answer is B
A. Bruising and bleeding gums are not indicative of an allergic reaction, which would typically present with different symptoms such as rash, itching, or swelling. Administering antihistamines would not address the underlying issue.
B. The development of bruising and bleeding gums in a patient on heparin therapy suggests a bleeding complication, which is a known risk of anticoagulation therapy. The nurse should notify the healthcare provider to assess the situation and possibly adjust treatment or perform further evaluations.
C. While hypersensitivity reactions can occur with medications, the symptoms presented here are more aligned with bleeding complications than with hypersensitivity. Discontinuing heparin without consulting the provider could put the patient at risk for thromboembolic events.
D. The symptoms do not indicate an infection; therefore, initiating antibiotic therapy would not be appropriate in this context.
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Correct Answer is ["A","B","E"]
Explanation
A. Improved sleep is an indication that fluoxetine is effectively alleviating depressive symptoms, as sleep disturbances are common in depression.
B. Decreased anxiety suggests that the medication is effective, as fluoxetine can help reduce both depressive and anxiety symptoms.
C. Reduced appetite is typically not a sign of effectiveness; it may indicate a side effect or worsening of depression rather than improvement.
D. Weight loss is also not a clear indicator of effectiveness; it may indicate adverse effects or worsening mental health symptoms rather than improvement in mood or behavior.
E. Interest in physical activity indicates improvement in mood and energy levels, which are positive signs of fluoxetine's effectiveness.
Correct Answer is A
Explanation
A. An INR of 5.0 indicates a significantly increased risk of bleeding, and administering vitamin K is the appropriate antidote for reversing the effects of warfarin. This is a critical intervention to restore coagulation.
B. Increasing the dose of warfarin is inappropriate in this scenario because the INR is already elevated; it would further increase bleeding risk.
C. While heparin can be used for anticoagulation, it is not appropriate to administer it while the INR is dangerously high without reversing the warfarin first.
D. Continuing warfarin is unsafe at this INR level due to the high risk of bleeding; monitoring for symptoms without intervention is not adequate care.