Author Question: Which action should the nurse take first when a patient develops a nosebleed? a. Pinch the lower ... (Read 63 times)

Bob-Dole

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Which action should the nurse take first when a patient develops a nosebleed?
 
  a. Pinch the lower portion of the nose for 10 minutes.
  b. Pack the affected nare tightly with an epistaxis balloon.
  c. Obtain silver nitrate that will be needed for cauterization.
  d. Apply ice compresses over the patient's nose and cheeks.

Question 2

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving?
 
  a. The patient lets the spouse provide tracheostomy care.
  b. The patient allows the nurse to suction the tracheostomy.
  c. The patient asks how to clean the tracheostomy stoma and tube.
  d. The patient uses a communication board to request No Visitors.



dellikani2015

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Answer to Question 1

ANS: A
The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

Answer to Question 2

ANS: C
Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.



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