A 7-year-old child with hemophilia A is brought to the emergency department after falling from a bicycle. Which assessment finding would be the nurse's highest priority concern?
The child fell onto his left side and is complaining of abdominal pain.
1Swelling and bruising on the left knee
2Increasing abdominal pain with guarding and rigidity✓ 정답
3Small superficial abrasions on both hands
4Complaint of headache rated 4/10 on pain scale
해설
In hemophilia A, the primary concern is internal bleeding, particularly intra-abdominal bleeding which can be life-threatening. Abdominal pain with guarding and rigidity indicates potential internal hemorrhage.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize care for a pediatric patient with Hemophilia A, a congenital bleeding disorder caused by a deficiency of clotting factor VIII. The core principle is that in bleeding disorders, internal bleeding into body cavities or organs poses a far greater immediate threat to life than external or superficial bleeding. The mechanism involves the inability to form a stable fibrin clot, leading to prolonged and potentially uncontrolled hemorrhage, even from minor trauma.
Answer Rationale: Key Point! Option ②, "Increasing abdominal pain with guarding and rigidity," is the highest priority. This classic presentation signals peritonitis, which in this context is most likely due to intra-abdominal hemorrhage. Bleeding into the peritoneal cavity can lead to massive blood loss, hypovolemic shock, and is a life-threatening emergency. It requires immediate intervention, including factor VIII replacement, vital sign monitoring, and possibly surgical consultation.
Distractor Analysis:
Watch out for confusion! Option ① (Swelling/bruising on the knee) is a common hemarthrosis (bleeding into a joint) in hemophilia. While it is painful and requires treatment with factor replacement to prevent joint damage, it is not immediately life-threatening and is therefore a lower priority than internal bleeding.
Option ③ (Superficial abrasions) involves minor external bleeding. In hemophilia, these may ooze longer but are easily managed with direct pressure and are the lowest priority.
Option ④ (Headache) must always be taken seriously in a patient with a bleeding disorder after head trauma due to the risk of intracranial hemorrhage (ICH). However, a mild, non-progressive headache (rated 4/10) without other neurological symptoms is less urgent than clear signs of an acute abdominal catastrophe. The nurse would monitor this closely, but the abdominal findings demand immediate action.
Related Concepts: The nursing process prioritization framework (e.g., ABCs—Airway, Breathing, Circulation, Maslow's Hierarchy) places threats to physiological integrity (circulation from internal bleeding) above pain management or localized injury. This scenario also integrates knowledge of pediatric assessment and the specific pathophysiology of coagulation disorders.
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in a pediatric ED. A 7-year-old boy with a known history of severe Hemophilia A is brought in by his anxious parents 30 minutes after a bicycle fall. He is pale, holding his abdomen, and whimpering.
Nursing Intervention Strategy:
1Immediate Assessment (ABCs)Quickly assess airway, breathing, and circulation. Check vital signs for tachycardia and hypotension, which are late signs of shock in children. Capillary refill >2 seconds is an early sign.
2Priority ActionAlert the physician/advanced practice provider immediately about the abdominal findings. Do not palpate the abdomen deeply, as this could worsen bleeding. Prepare for STAT labs (CBC, coagulation studies, type and cross) and IV access.
3Definitive TreatmentThe cornerstone of care is the rapid administration of Factor VIII concentrate. As the nurse, you must ensure it is reconstituted and administered correctly and promptly. Monitor for any adverse reactions.
4Ongoing MonitoringMonitor abdominal girth, pain level, and vital signs frequently. Maintain strict bed rest. Provide non-pharmacological comfort measures and administer prescribed analgesics (avoid aspirin and NSAIDs).
Patient Safety and Precautions:
* Medication Alert: Never give intramuscular (IM) injections to a patient with hemophilia. All medications should be given orally or intravenously (IV).
* Activity: After acute management, coordinate with physical therapy for safe mobility and joint protection education.
Nursing Procedure & Medication FlowAdministering Factor VIII Concentrate:
1. Verify the order and perform independent double-check with another nurse.
2. Reconstitute the lyophilized powder with the provided sterile diluent.
3. Administer IV via a pump at the prescribed rate (often over 5-15 minutes). Too rapid infusion can cause flushing, tachycardia, or headache.
4. Monitor closely during infusion for signs of an allergic reaction (hives, wheezing, chest tightness).
5. Document the lot number, dose, time, and the patient's response.
A Word from Your Senior Nurse
"In the ED, your gut feeling and prioritization skills save lives. With a bleeding disorder, think 'inside out.' The bruise you can see is often less dangerous than the bleed you can't. That child with abdominal guarding? Your rapid recognition and escalation of care are what will get him the life-saving factor infusion he needs. On the NCLEX, they're testing this clinical judgment—can you spot the silent killer among the noisy complaints?"
Hemophilia A — An X-linked recessive bleeding disorder characterized by a deficiency of clotting factor VIII, leading to prolonged bleeding after injury and spontaneous bleeding into joints and muscles.
Hemarthrosis — Bleeding into a joint space. A hallmark complication of hemophilia, causing pain, swelling, warmth, and limited range of motion. Repeated episodes can lead to chronic arthropathy.
Intra-abdominal Hemorrhage — Bleeding within the peritoneal cavity. A life-threatening emergency in patients with bleeding disorders, presenting with pain, guarding, rigidity, distension, and signs of hypovolemia.
Guarding and Rigidity — Physical exam findings of the abdomen. Guarding is voluntary contraction of abdominal muscles due to pain. Rigidity is an involuntary, board-like hardness of the abdominal wall, a key sign of peritonitis often caused by internal bleeding or infection.
Factor VIII Concentrate — The definitive treatment for bleeding episodes in Hemophilia A. It is a lyophilized powder of the missing clotting factor, reconstituted and administered intravenously to achieve hemostasis.