While bathing a patient with cancer,the nurse assessed several large new bruises on the patient's upper arms and thighs.An understanding of the possible causes and the correct nurse's actions for these findings are that:
A) The patient must have fallen last night walking to the bathroom. Teach the patient to use the call bell when assistance is needed.
B) The patient may have disseminated intravascular coagulation. The size, shape, location, color, and tenderness must be reported and recorded fully.
C) An intravascular fluid overload is occurring because of the chemotherapy. Place the patient on strict input/output (I/O) status and limit fluids.
D) The patient must have had a drug-induced seizure, which caused arm and leg thrashing and the bruises. Report and record the findings, and pad the side rails.
Correct Answer:
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