A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

Bradycardia

Increased blood pressure

Warm, flushed skin

Decreased urine output

Answer and Explanation

The Correct Answer is B

A) Incorrect. Bradycardia is not typically an early sign of compensatory response to hypovolemia. The body often responds to hypovolemia with an increased heart rate (tachycardia).

B) Correct. In the early stages of hypovolemia, the body may attempt to compensate by increasing blood pressure to maintain perfusion to vital organs.

C) Incorrect. Warm, flushed skin may be present in the initial stages of hypovolemia, but it is not necessarily an early sign of compensatory response.

D) Incorrect. Decreased urine output is a later sign of hypovolemia when the body's compensatory mechanisms are no longer effective in maintaining blood flow to the kidneys.

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Correct Answer is C

Explanation

A) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding, so it should be avoided in clients at risk of hemorrhage.

B) Incorrect. Encouraging the client to participate in contact sports can increase the risk of trauma and bleeding, and it is not a preventive action.

C) Correct. Using a soft-bristled toothbrush for oral care can prevent gum and oral tissue injury, reducing the risk of bleeding in vulnerable clients.

D) Incorrect. Monitoring platelet levels daily is not a preventive action but a method of assessing the client's clotting status.

Questions

A. Swelling and bruising around the wound. B. Cool and pale skin in the extremities. C. Blood oozing from the wound site. D. Visible blood clot formation.

Correct Answer is B

Explanation

A) Incorrect. Swelling and bruising around the wound are common signs of external bleeding and do not directly indicate internal bleeding.

B) Correct. Cool and pale skin in the extremities may be indicative of vasoconstriction and reduced blood flow, which can occur in response to internal bleeding.

C) Incorrect. Blood oozing from the wound site is a typical sign of external bleeding and does not necessarily indicate internal bleeding.

D) Incorrect. Visible blood clot formation at the wound site is a normal part of the body's hemostatic response to control external bleeding and does not directly suggest internal bleeding.

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A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

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Naxlex Comprehensive Predictor Exams

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