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 A

Explanation

A) Correct. Dizziness and lightheadedness are common signs of decreased blood flow, indicating a potential worsening of internal bleeding. Immediate intervention is required to prevent further complications.

B) Incorrect. While a slightly decreased blood pressure could be a concern, it may not be an immediate priority. The nurse should closely monitor the blood pressure and respond promptly if it drops significantly or trends downward.

C) Incorrect. Pale and cool skin may indicate poor perfusion, but it doesn't necessarily require immediate intervention unless it worsens or is accompanied by other alarming signs.

D) Incorrect. Although heart rate can be affected by hemorrhage, being within the normal range doesn't necessarily warrant immediate intervention. Other signs and symptoms should be considered as well.

A. Bradycardia B. Hypotension C. Pallor D. Restlessness

Correct Answer is D

Explanation

A) Incorrect. Bradycardia is not typically an early clinical manifestation of hemorrhage. The body may initially compensate for the blood loss by increasing heart rate (tachycardia).

B) Incorrect. Hypotension may occur later in the course of hemorrhage as blood loss progresses, but it is not an early manifestation.

C) Incorrect. Pallor (pale skin) may occur later as a result of decreased blood volume, but it is not an early sign.

D) Correct. Restlessness and anxiety are early manifestations of hemorrhage, reflecting the body's compensatory response to maintain perfusion in the early stages of blood loss.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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