A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client?
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.
Correct Answer: 1, 3, 5
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. 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. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. A deviated septum is not associated with epistaxis.
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