Exam 4: Hematologic/Immune Dysfunction NCLEX Questions

b

What is the cause for the signs and symptoms when hemoglobin falls sufficiently to produce clinical manifestations? a. Phagocytosis b. Tissue hypoxia c. Pulmonary hypertension d. Depressed bone marrow

a

A nurse is providing teaching about the management of epistaxis to an adolescent. Which of the following positions should the nurse instruct the adolescent to take when experiencing a nosebleed? a. sit up and lean forward b. sit up and tilt the head c. lie in a supine position d. lie in a prone position

b

Hereditary spherocytosis is a. always transmitted as an autosomal recessive disease b. a hemolytic disorder caused by a defect in the proteins that form the RBC membrane c. rarely evident until the infant is 4-6 months of age d. usually resolved when additional folic acid supplements are administered

c

In a child with sickle cell anemia (SCA), adequate hydration is essential to minimize sickling and delay the vasoocclusion and hypoxiaischemia cycle. What information should the nurse share with parents in a teaching plan? a. Encourage drinking. b. Keep accurate records of output. c. Check for moist mucous membranes. d. Monitor the concentration of the childs urine.

b

In anticipation of the admission of a child with hereditary spherocytosis (HS) who is experiencing an aplastic crisis, what action should the nurse plan? a. Secure an isolation room. b. Prepare for a transfusion of packed red blood cells. c. Anticipate preoperative preparation for a splenectomy. d. Gather equipment and medication for treatment of shock.

a

In which condition are all the formed elements of the blood simultaneously depressed? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia

b

Lucas, age 7 years, is receiving a transfusion of packed RBCs. After 45 minutes, he begins to have chills, fever, a sensation of tightness in the chest, and headache. The priority action of the nurse is to a. stop the transfusion, maintain a patent IV line with normal saline and new tubing, and administer acetaminophen b. stop the transfusion, maintain a patent IV line with normal saline and new tubing, and notify the practitioner c. slow the transfusion rate until the symptoms subside d. slow the transfusion and send a sample of the patient's blood and urine to the laboratory

b

Patricia Marshall, age 12 years, is admitted to your unit with a diagnosis of sickle cell crisis. Which of the following activities is most likely to have precipitated this episode? a. attending the football game with her friends b. going camping and hiking in the mountains with her friends c. going to the beach and surfing with her friends d. staying indoors and reading for several hours

a d e

What activity should the school nurse recommend for a child with hemophilia A? Select all that apply a. Golf b. Soccer c. Rugby d. Jogging e. Swimming

d

What is the most appropriate method to use when drawing blood from a child with hemophilia? a. use finger punctures for lab draws b. prepare to administer platelets c. apply heat to the extremity before venipunctures d. schedule all labs to be drawn at one time

b

A child with sickle cell anemia (SCA) develops severe chest and back pain, fever, a cough, and dyspnea. What should be the first action by the nurse? a. Administer 100% oxygen to relieve hypoxia. b. Notify the practitioner because chest syndrome is suspected. c. Infuse intravenous antibiotics as soon as cultures are obtained. d. Give ordered pain medication to relieve symptoms of pain episode.

b d e

A child with sickle cell anemia is admitted in a vaso-occlusive crisis. Which of the following interventions should the nurse expect to see ordered? Select all that apply a. cold compresses to painful joints b. IV fluids started, and oral fluids encouraged c. meperidine ordered every 4 hours for pain d. high calorie, high protein diet e. antibiotics ordered for any existing infection

b

A child with sickle cell disease is in a vasoocclusive crisis. What nonpharmacologic pain intervention should the nurse plan? a. Exercise as a distraction b. Heat to the affected area c. Elevation of the extremity d. Cold compresses to the affected area

a

A 5-year-old child is admitted to the hospital in a sickle cell crisis. The child has been alert and oriented but in severe pain. The nurse notes that the child is complaining of a headache and is having unilateral hemiplegia. What action should the nurse implement? a. Notify the health care provider. b. Place the child on bed rest. c. Administer a dose of hydrocodone (Vicodin). d. Start O2 per the hospitals protocol.

a b e

A child with hemophilia A fell and injured a knee while playing outside. The knee is swollen and painful. Which of the following measures should be taken to stop the bleeding? Select all that apply a. the extremity should be immobilized b. the extremity should be elevated c. warm moist compresses should be applied to decrease pain d. passive ROM exercises should be administered to the extremity e. factor VIII should be administered

a

A child with hemophilia A is scheduled for surgery. What precautions should the nurse institute with this child? a. Handle the child gently when transferring to a cart. b. Caution the child not to brush his teeth before surgery. c. Use tape sparingly on postoperative dressings. d. Do not administer analgesics before surgery.

d

A child with hemophilia A will have which abnormal laboratory result? a. PT (ProTime) b. Platelet count c. Fibrinogen level d. PTT (partial thromboplastin time)

b

A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide factor replacement and a. administer an aspirin containing compound b. institute rest, ice, compression, and elevation (RICE) c. begin physical therapy with active ROM d. initiate skin traction

c

A child with severe anemia requires a unit of red blood cells (RBCs). The nurse explains to the child that the transfusion is necessary for which reason? a. Allow her parents to come visit her. b. Fight the infection that she now has. c. Increase her energy so she will not be so tired. d. Help her body stop bleeding by forming a clot (scab).

b

A nurse instructs the parent of a child with sickle cell disease about factors that might precipitate a pain crisis in the child. Which of the following factors identified by the parent as being able to cause a pain crisis indicates a need for further teaching? a. infection b. overhydration c. stress at school d. cold environment

d

An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of what complication? a. Air embolism b. Allergic reaction c. Hemolytic reaction d. Circulatory overload

b

Care for the child with acute idiopathic thrombocytopenic purpura (ITP) includes which therapeutic intervention? a. Splenectomy b. Intravenous administration of anti-D antibody c. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) d. Helping child participate in sports

d

For children who do not have a matched sibling bone marrow donor, the therapeutic management of aplastic anemia includes what intervention? a. Antibiotics b. Antiretroviral drugs c. Iron supplementation d. Immunosuppressive therapy

c

Gary Berringer is a 5 year old being admitted because of diminished RBC production triggered by a viral infection. What type of sickle cell crisis is he most likely experiencing? a. vasoocclusive crisis b. splenic sequestration crisis c. aplastic crisis d. hyperhemolytic crisis

a

In planning for a child's discharge after a sickle cell crisis, the nurse recognizes which of the following as a critical factor to include in the teaching plan? a. ingestion of large quantities of liquids to promote adequate hydration b. rigorous exercise schedule to promote muscle strength c. a high-caloric diet to improve nutrition d. at least 12 hours of sleep per night to promote adequate rest

c

Infants are often not diagnosed with sickle cell anemia until they are 1 year of age. Why? a. usually there are no symptoms until after age 1 b. high intake of fluids from formula prevents sickle cell crises during this age c. fetal hemoglobin is present during the first year of life d. increased hemoglobin and hematocrit amounts compensate during this period

c

Persons diagnosed with sickle cell trait a. have 50% or more of the total hemoglobin in HgbS b. cannot pass the trait to their children c. can have painful gross hematuria as a major complication d. never develop symptoms of anemia

d

The clinic nurse instructs parents of a child with sickel cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? a. stress b. trauma c. infection d. fluid overload

c

The clinical manifestations of sickle cell anemia (SCA) are primarily the result of which physiologic alteration? a. Decreased blood viscosity b. Deficiency in coagulation c. Increased red blood cell (RBC) destruction d. Greater affinity for oxygen

a

What rationale explains why prolonged use of oxygen should be discouraged in a child with anemia? a. Prolonged use of oxygen can decrease erythropoiesis. b. Prolonged use of oxygen can interfere with iron production. c. Prolonged use of oxygen interferes with a childs appetite. d. Prolonged use of oxygen can affect the synthesis of hemoglobin.

d

What statement best describes iron deficiency anemia in infants? a. It is caused by depression of the hematopoietic system. b. Diagnosis is easily made because of the infants emaciated appearance. c. It results from a decreased intake of milk and the premature addition of solid foods. d. Clinical manifestations are related to a reduction in the amount of oxygen available to tissues.

c

A mother states that she brought her child to the clinic because the 3-year-old girl was not keeping up with her siblings. During physical assessment, the nurse notes that the child has pale skin and conjunctiva and has muscle weakness. The hemoglobin on admission is 6.4 g/dl. After notifying the practitioner of the results, what nursing priority intervention should occur next? a. Reduce environmental stimulation to prevent seizures. b. Have the laboratory repeat the analysis with a new specimen. c. Minimize energy expenditure to decrease cardiac workload. d. Administer intravenous fluids to correct the dehydration.

c d e

A nurse is caring for a 5 year old with sickle cell vaso-occlusive crisis. Which of the following orders should the nurse question? Select all that apply a. position the child for comfort b. apply hot packs to painful areas c. give meperidine (Demerol) 25 mg IV every 4 hours as needed for pain d. restrict oral fluids e. apply oxygen per nasal cannula to keep oxygen saturations above 94%

b

A nurse is caring for an infant whose screening test reveals a possible diagnosis of sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease? a. sickle solubility test b. hemoglobin electrophoresis c. complete blood count d. transcranial doppler

b

A nurse is preparing to administer iron dextran IM to a school-age child who has iron deficiency anemia. Which of the following actions by the nurse is appropriate? a. administer the dose in the deltoid muscle b. use the Z-track method when administering the dose c. avoid injecting more than 2 mL with each dose d. massage the injection site for 1 minute after administering the dose

a c

A nurse is providing teaching about epistaxis to the parent of a school-age child. Which of the following should the nurse include as an action to take when managing an episode of epistaxis? Select all that apply a. press the nares together for at least 10 minutes b. breathe through the nose until bleeding stops c. pack cotton or tissue into the naris that is bleeding d. apply a warm cloth across the bridge of the nose e. insert petroleum into the naris after the bleeding stops

d

A nurse is providing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parent indicates an understanding of teaching? a. "I should take my child to the ER if his stools become dark" b. "my child should avoid eating citrus fruits while taking the supplements" c. "I should give the iron with milk to help prevent an upset stomach" d. "my child should take the supplement through a straw"

a

A school-age child is admitted in vasoocclusive sickle cell crisis (pain episode). The childs care should include which therapeutic interventions? a. Hydration and pain management b. Oxygenation and factor VIII replacement c. Electrolyte replacement and administration of heparin d. Correction of alkalosis and reduction of energy expenditure

a

A toddler is diagnosed with chronic benign neutropenia. The parents are being taught about caring for their child. What information is important to include? a. Avoid large indoor crowds and people who are ill. b. Parenteral antibiotics are necessary to control disease. c. Frequent rest periods are needed during the daytime. d. List the side effects of corticosteroids used to decrease inflammation.

a c d

The clinic nurse is evaluating causes for iron deficiency caused by inadequate supply of iron. What should the nurse recognize as causes for iron deficiency caused by an inadequate iron supply? Select all that apply a. Prematurity b. Slow growth rate c. Excessive milk intake d. Severe iron deficiency in the mother e. Exclusive breastfeeding of infant from birth to 3 months

b c e

The clinic nurse is evaluating causes for iron deficiency due to impaired iron absorption. What should the nurse recognize as causes for iron deficiency due to impaired iron absorption? Select all that apply a. Gastric acidity b. Chronic diarrhea c. Lactose intolerance d. Absence of phosphates e. Inflammatory bowel disease

d

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? a. platelet count b. hematocrit level c. hemoglobin level d. partial thromboplastin time

a b c e

The nurse is administering a unit of blood to a child. What are signs and symptoms of a transfusion reaction? Select all that apply a. Chills b. Shaking c. Flank pain d. Hypothermia e. Sudden severe headache

a c d

The nurse is caring for a child who is receiving a transfusion of PRBCs. The nurse is aware that if the child has a hemolytic reaction to the blood, the signs and symptoms would include which of the following? Select all that apply a. fever b. rash c. oliguria d. hypotension e. chills

d

The nurse is caring for a child with hemophilia A. The childs activity is as tolerated. What activity is contraindicated for this child? a. Ambulating to the cafeteria b. Active range of motion c. Ambulating to the playroom d. Passive range of motion exercises

b

The nurse is caring for a child with sickle cell disease who is scheduled to have a splenectomy. What information should the nurse explain to the parents regarding the reason for a splenectomy a. to decrease potential for infection b. to prevent splenic sequestration c. to prevent sickling of red blood cells d. to prevent sickle cell crisis

b

The nurse is caring for a school-age child with severe anemia and activity intolerance. What diversional activity should the nurse plan for this child? a. Playing a musical instrument b. Playing board or card games c. Participating in a game of table tennis d. Participating in decorating the hospital room

d

The nurse is explaining blood components to an 8-year-old child. What is the nurse's best description and action of platelets? a. Make up the liquid portion of blood. b. Help keep germs from causing infection. c. Carry the oxygen you breathe from your lungs to all parts of your body. d. Help your body stop bleeding by forming a clot (scab) over the hurt area.

d

The nurse is instructing a new mother in how to prevent iron-deficiency anemia in her new premature infant when she takes her home. The mother intends to breastfeed. Which of the following statements reflects a need for further teaching? a. "I will use only breast milk or formula as a source of milk for my baby until she is at least 12 months old" b. "My baby will need to have iron supplements introduced when she is 2 months old" c. "As my baby is able to tolerate other foods, such as cereal, I should limit her formula intake to about 1 liter per day to encourage intake of iron-rich cereals" d. "I will need to add iron supplements to my baby's diet when she is 6 months old"

b

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administrating of a liquid oral iron supplement. Which instruction should the nurse tell the parents? a. administer the iron at mealtimes b. administer the iron through a straw c. mix the iron with cereal to administer d. add the iron to formula for easy administration

a

The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. What is the priority nursing goal? a. Prevent infection. b. Prevent secondary cancers. c. Identify source of infection. d. Restore immunologic defenses.

d

The nurse is preparing to administer a unit of packed red blood cells to a hospitalized child. What is an appropriate action that applies to administering blood? a. Take the vital signs every 15 minutes while blood is infusing. b. Use blood within 1 hour of its arrival from the blood bank. c. Administer the blood with 5% glucose in a piggyback setup. d. Administer the first 50 ml of blood slowly and stay with the child.

c

The nurse is providing home care instructions to the parents of a 10 year old child with hemophilia. Which sport activity should the nurse suggest for this child? a. soccer b. basketball c. swimming d. field hockey

c d e

The nurse is teaching parents of a child being discharged from the hospital after a splenectomy about the risk of infection. What should the nurse include in the teaching session? Select all that apply a. Avoid obtaining the pneumococcal vaccination for the child. b. Avoid obtaining the meningococcal vaccination for the child. c. The child should receive prophylactic penicillin for certain procedures. d. Have the child immunized with the Haemophilus influenzae type b vaccination. e. Notify the health care provider if your child develops a fever of 38.5 C (101.3 F).

c

The nurse is teaching the family of a child, age 8 years, with moderate hemophilia about home care. What should the nurse tell the family to do to minimize joint injury? a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs). b. Administer DDAVP (synthetic vasopressin). c. Provide intravenous (IV) infusion of factor VIII concentrates. d. Encourage elevation and application of ice to the involved joint.

b

The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how to prevent sickle cell crisis, the nurse should include which instructions? a. exercise in cool temperatures b. drink at least 2 quarts of fluids per day c. avoid contact sports d. take anti-inflammatory medications before exercising

d

The nurse suspects a child is having an adverse reaction to a blood transfusion. What is the initial action by the nurse? a. Notify the physician. b. Take the vital signs and blood pressure and compare them with baseline levels. c. Dilute infusing blood with equal amounts of normal saline. d. Stop transfusion and maintain a patent intravenous line with normal saline and new tubing.

d

The parent of a child receiving an iron preparation tells the nurse that the child's stools are a tarry green color. What information does the nurse included in discussion with this parent? a. Symptom of iron-deficiency anemia b. Adverse effect of the iron preparation c. Indicator of an iron preparation overdose d. Normally expected change resulting from the iron preparation

b

The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. The nurse would explain what concerning narcotic analgesics? a. They are often ordered but not usually needed. b. When they are medically indicated, children rarely become addicted. c. They are given as a last resort because of the threat of addiction. d. They are used only if other measures, such as ice packs, are ineffective.

c

The parents of a child with sickle cell anemia (SCA) are concerned about subsequent children having the disease. What statement most accurately reflects inheritance of SCA? a. SCA is not inherited. b. All siblings will have SCA. c. Each sibling has a 25% chance of having SCA. d. There is a 50% chance of siblings having SCA.

c

The school nurse is caring for a child with hemophilia who fell on his arm during recess. What supportive measures would the nurse implement first? a. Apply warm, moist compresses. b. Apply a tourniquet for at least 5 minutes. c. Elevate the arm above the level of the heart. d. Begin passive range of motion unless pain is severe.

d

The school nurse is discussing prevention of acquired immunodeficiency syndrome with some adolescents. What is appropriate to include? a. The virus is easily transmitted. b. It is only transmitted through blood. c. Condoms should be used if adolescents are homosexual. d. Recreational drug users should not share needles or other equipment.

a

Therapeutic management of a 6-year-old child with hereditary spherocytosis (HS) should include which therapeutic intervention? a. Perform a splenectomy. b. Supplement the diet with calcium. c. Institute a maintenance transfusion program. d. Increase intake of iron-rich foods such as meat.

d

Therapeutic management of sickle cell crisis generally includes which of the following? a. long term oxygen use to enable the oxygen to reach the sickled RBCs b. decrease in fluids to increase hemoconcentration c. diet high in iron to decrease anemia d. bed rest to minimize energy expenditure

d

To control pain related to vasoocclusive sickle cell crisis, which of the following can the nurse expect to be included in the care plan? a. administration of long-term oxygen b. application of cold compresses to the area c. administration of meperidine (Demerol) titrated to a therapeutic level d. codeine added to acetaminophen or ibuprofen if neither one of these is effective in relieving the pain alone

d

Two year old Karen Lumia is HIV infected. Her mother is concerned about placing Karen in daycare and is discussing this with the nurse at a routine pediatric follow up visit. Which of the following is the best information to provide Karen's mother? a. the risk for HIV transmission is significant in daycare centers. Karen should not go to daycare until she is older b. it will be alright for Karen to attend the daycare, but Karen's mother must tell the daycare that Karen is infected c. Karen can go to the daycare but will not be allowed to participate in sports or physical activity that could lead to injury d. Karen should be admitted to the daycare without restrictions and allowed to participate in all activities as her health permits

a b e

What are signs and symptoms of anemia? Select all that apply a. Pallor b. Fatigue c. Dilute urine d. Bradycardia e. Muscle weakness

c

What condition is an acquired hemorrhagic disorder that is characterized by excessive destruction of platelets? a. Aplastic anemia b. Thalassemia major c. Idiopathic thrombocytopenic purpura d. Disseminated intravascular coagulation

b

What condition occurs when the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Iron deficiency anemia

d

What condition precipitates polycythemia? a. Dehydration b. Severe infections c. Immunosuppression d. Prolonged tissue hypoxia

a

What explanation provides the rationale for why iron-deficiency anemia is common during infancy? a. Cows milk is a poor source of iron. b. Iron cannot be stored during fetal development. c. Fetal iron stores are depleted by 1 month of age. d. Dietary iron cannot be started until 12 months of age.

c

What information should the nurse include when teaching the mother of a 9-month-old infant about administering liquid iron preparations? a. Give with meals. b. Stop immediately if nausea and vomiting occur. c. Adequate dosage will turn the stools a tarry green color. d. Allow preparation to mix with saliva and bathe the teeth before swallowing.

b

What is a priority nursing consideration when caring for a child with sickle cell anemia? a. Refer the parents and child for genetic counseling. b. Teach the parents and child how to recognize the signs and symptoms of crises. c. Help the child and family adjust to a short-term disease. d. Observe for complications of multiple blood transfusions.

a

When discussing hemophilia with the parents of a child recently diagnosed with this disease, the nurse tells the parents that a. hemophilia is an X-linked disorder in which the mother is the carrier of the illness but is not affected by it b. hemophilia is a recessive disorder carried by either the mother or father c. all daughters of the parents will be carriers d. each of their sons has a 75% chance of being affected

a

When teaching the parents of 4 year old Tony how to administer the iron supplement ordered for his iron deficiency, the nurse should include which of the following in the teaching plan? a. give the iron twice daily in divided doses with orange juice b. give the iron twice daily with milk c. administer the oral liquid iron preparation with the use of a syringe or medicine dropper directly into each side of the mouth in the cheek areas d. make certain the parents have at least a 3 month supply of the iron preparation on hand so they will not run out

b

When the hemoglobin level falls sufficiently to produce clinical manifestations of anemia, the patient experiences a. cyanosis b. tissue hypoxia c. nausea and vomiting d. feelings of anxiety

c

Which is the most accurate genetic explanation for a family with hemophilia? a. it is a y-linked dominant disorder b. it is equally distributed among males and females c. it is an x-linked recessive disorder d. it is an autosommal recessive disorder

a b c d

Which of the following activities should a nurse suggest for a client diagnosed with hemophilia? Select all that apply a. swimming b. golf c. hiking d. fishing e. soccer

b c e

Which of the following describes idiopathic thrombocytopenia purpura? Select all that apply a. ITP is a congenital hematological disorder b. ITP causes excessive destruction of platelets c. children with ITP have normal bone marrow d. platelets are small in ITP e. purpura is observed in ITP

d

Which of the following diagnostic tests can distinguish between those children with sickle cell trait and those with sickle cell disease? a. CBC with differential b. sickledex c. bleeding time d. hemoglobin electrophoresis

a c d e

Which of the following factors needs to be included in a teaching plan for a child with sickle cell disease? Select all that apply a. the child needs to be taken to a physician when sick b. the parent should make sure the child sleeps in an air conditioned room c. emotional stress should be avoided d. it is important to keep the child well hydrated e. it is important to make sure the child gets adequate nutrition

a

Which of the following is an acquired hemorrhagic disorder characterized by thrombocytopenia, absence of severe signs of bleeding, and normal bone marrow with a normal or increased number of immature magakaryocytes and eosinophils? a. immune thrombocytopenia b. disseminated intravascular coagulation c. acute-onset neutropenia d. hemoch-schonlein purpura

a

Which of the following is the most frequent form of internal bleeding in the child with hemophilia? a. hemarthrosis b. epistaxis c. intracranial hemorrhage d. gastrointestinal tract hemorrhage

d

Which of the following measures should the nurse teach the parent of a child with hemophilia to do first if the child sustains an injury to a joint causing bleeding? a. give the child a dose of acetaminophen b. immobilize the joint and elevate the extremity c. apply heat to the area d. administer factor per the home-care protocol

a

Which of the following statements about chronic benign neutropenia is true? a. nursing care management includes educating parents to keep their child away from crowded areas and individuals who are ill b. diagnosis is usually made when the child is seen with weight loss and fatigue c. the absolute neutrophil count is usually 1500/mm or less at the time of diagnosis d. children do not receive chronic childhood immunization because of the abnormal cellular immunity and antineutrophil antibodies associated with this disorder

b

Which test provides a definitive diagnosis of aplastic anemia? a. complete blood count with differential b. bone marrow aspiration c. serum IgG levels d. basic metabolic panel

b c e

You are discharging a patient with hemophilia. Which of the following responses by the parents indicate an understanding of this disorder? Select all that apply a. "my child should remain active to decrease joint problems, and most children with hemophilia can participate in the same activities as peers" b. "care should be taken to avoid bleeding of gums, and softening of the toothbrush in warm water before brushing or using a sponge-tipped disposable toothbrush may be helpful" c. "signs of internal bleeding should be recognized, such as headache, slurred speech, loss of consciousness, and black tarry stools" d. "if there is bleeding in a joint, elevation, ice, and rest should help and may prevent the need for factor VIII replacement" e. "all of my son's teachers need to be aware of what to do if he gets a bloody nose"