The nurse is triaging several patients in an urgent care center. One patient states that he has hemophilia and is bleeding, with no apparent signs of bleeding. Which priority action by the nurse is most appropriate at this time?
Have the patient take a number and stay in the waiting area.
Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis.
Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room.
Palpate the suspected area of bleeding for tenderness and edema.
The Correct Answer is B
A. Have the patient take a number and stay in the waiting area. Delaying care could lead to worsening of a potentially life-threatening bleeding episode. Hemophilia patients should be assessed promptly.
B. Place the patient in an examination room immediately and notify the physician of a potential bleeding crisis. Hemophilia patients are at risk of internal bleeding, which may not always be visible externally. Rapid assessment is essential to prevent complications from internal bleeding.
C. Send the patient for routine x-rays to locate the source of bleeding and place him in an examination room. X-rays may not immediately detect bleeding in soft tissues. The physician should evaluate the patient first.
D. Palpate the suspected area of bleeding for tenderness and edema. Palpating could worsen bleeding or cause pain, and the nurse should focus on ensuring the patient is seen promptly by the physician.
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Correct Answer is A
Explanation
A. Results indicate the presence of Reed Sternberg cells: Reed-Sternberg cells are a defining characteristic of Hodgkin disease, a type of lymphoma. Their presence in biopsy samples confirms the diagnosis, distinguishing Hodgkin disease from other types of lymphomas and leukemias.
B. The patient is cyanotic: Cyanosis, or bluish skin discoloration due to low oxygen levels, is not a common sign of Hodgkin disease. It may occur in advanced disease due to respiratory compromise but is not a defining characteristic.
C. The patient is complaining of excessive thirst and hunger: Excessive thirst and hunger are more characteristic of diabetes mellitus, not Hodgkin disease. These symptoms are unrelated to the lymphatic involvement seen in Hodgkin disease.
D. Results indicate the presence of the Philadelphia chromosome: The Philadelphia chromosome is a genetic abnormality associated with chronic myelogenous leukemia (CML), not Hodgkin disease. Its presence suggests a different hematologic malignancy.
Correct Answer is C
Explanation
A. Folate: Folate is important for red blood cell production but does not address the Vitamin B12 deficiency seen in pernicious anemia.
B. Vitamin C: Vitamin C does not impact pernicious anemia as it is not involved in Vitamin B12 absorption.
C. Vitamin B12: Pernicious anemia occurs due to a lack of intrinsic factor, which is necessary for Vitamin B12 absorption. After a total gastrectomy, intrinsic factor is no longer produced, requiring Vitamin B12 supplementation.
D. Iron: Iron deficiency anemia is different from pernicious anemia, which specifically requires Vitamin B12 supplementation.