A male client with multiple injuries is brought to the ED by ambulance. His airway is stabilized and he is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?
Rapid pulse and prolonged capillary refill
Increased BP with narrowed pulse pressure
Sudden diaphoresis
Increasing urinary output
The Correct Answer is A
A. Rapid pulse and prolonged capillary refill: A rapid pulse combined with delayed capillary refill strongly suggests poor perfusion and early hypovolemic shock. These findings indicate that the body is compensating for volume loss by increasing heart rate and redirecting blood to vital organs. Capillary refill slows as peripheral circulation decreases.
B. Increased BP with narrowed pulse pressure: Increased blood pressure does not align with internal bleeding, as hypovolemia typically causes the pressure to fall rather than rise. Narrowed pulse pressure can occur in shock, but pairing it with elevated BP makes internal hemorrhage less likely.
C. Sudden diaphoresis: Diaphoresis can occur with pain, anxiety, fever, or sympathetic activation, making it nonspecific. While it may accompany early shock, it does not reliably indicate internal bleeding on its own. The absence of other hemodynamic changes limits its diagnostic value. More definitive perfusion changes would be expected in hemorrhage.
D. Increasing urinary output: Rising urine output generally reflects adequate renal perfusion and fluid status, which contradicts signs of internal hemorrhage. As bleeding progresses, urine output typically declines due to reduced circulating volume. An increase suggests stability rather than deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Lactated Ringer's at 150 mL/hr: Large-volume fluid administration increases preload, which can worsen pulmonary congestion and stress an already failing heart. In cardiogenic shock, the problem is pump failure rather than fluid deficit, making aggressive fluid infusion harmful. This intervention increases myocardial workload instead of reducing it.
B. Morphine sulfate 4 mg IV: Morphine decreases preload and afterload through venous dilation, which reduces the heart’s workload and oxygen demand. It also decreases anxiety and sympathetic stimulation, helping limit further cardiac strain. These effects support myocardial rest and improved efficiency.
C. Norepinephrine 2 mg/min: Norepinephrine causes potent vasoconstriction that raises afterload, forcing the failing heart to pump against greater resistance. This can worsen cardiac workload and oxygen consumption in cardiogenic shock. It is usually avoided unless severe hypotension is present and unresponsive to other treatments.
D. Dobutamine 3 mcg/kg/min: Dobutamine improves contractility and cardiac output, but it also increases myocardial oxygen demand. While helpful for improving perfusion, it does not primarily reduce workload. Its inotropic effect can stress the heart further if not titrated carefully. It is supportive but not the priority intervention for conserving energy.
Correct Answer is D
Explanation
A. Inspiratory crackles: Crackles indicate fluid accumulation in the lungs, often seen in cardiogenic or hypovolemic issues, not neurogenic shock. Pulmonary findings are not characteristic of neurogenic shock.
B. Temp. 101.2 F: Fever suggests infection or inflammatory processes, which are not defining features of neurogenic shock. Temperature elevation does not help confirm the presence of neurogenic shock.
C. Cool, clammy skin: Neurogenic shock typically causes vasodilation, leading to warm, dry skin rather than cool, clammy skin. Cool, clammy skin is more associated with hypovolemic or cardiogenic shock.
D. Heart rate 48 bpm: Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic activity following spinal cord injury. Along with hypotension and vasodilation, bradycardia helps confirm the diagnosis. This vital sign is key in differentiating it from other shock types.
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