A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two days. Which of the following assessments would be a priority for the nurse is this situation? Standard Text: Select all that apply
1. Request information from the client regarding increased propensity for bruising or bleeding.
2. Assess the tonsils for redness or swelling.
3. Obtain a blood pressure.
4. Check for deviated septum.
5. Request information from the client to determine if there was any recent thin, watery drainage from the nose.
1,3,5
Rationale 1: Request information from the client regarding increased propensity for bruising or bleeding. The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis.
Rationale 2: Assess the tonsils for redness or swelling. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis.
Rationale 3: Obtain a blood pressure. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the client's blood pressure to determine if it is elevated.
Rationale 4: Check for deviated septum. A deviated septum is not associated with epistaxis.
Rationale 5: Request information from the client to determine if there was any recent thin, watery drainage from the nose. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis.
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