A nurse is caring for a client who experienced external bleeding from a leg wound. Which finding should the nurse recognize as a potential sign of internal bleeding?

Swelling and bruising around the wound.

Cool and pale skin in the extremities.

Blood oozing from the wound site.

Visible blood clot formation.

Answer and Explanation

The Correct Answer is B

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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Correct Answer is A

Explanation

A) Correct. In liver cirrhosis, the damaged liver may sequester platelets, leading to a decreased platelet count. However, an elevated platelet count (thrombocytosis) can occur as a compensatory response to decreased liver function and is a sign of an increased risk of hemorrhage due to poor clot formation.

B) Incorrect. Low prothrombin time (PT) indicates faster clotting and is not associated with an increased risk of hemorrhage.

C) Incorrect. Decreased ammonia levels are a positive finding in liver cirrhosis, as elevated ammonia levels are harmful to the brain.

D) Incorrect. Elevated liver enzymes are indicative of liver damage, but they do not directly impact the client's risk of hemorrhage.

A. Computed Tomography (CT) scan B. Complete Blood Count (CBC) C. Electrocardiogram (ECG) D. Magnetic Resonance Imaging (MRI)

Correct Answer is A

Explanation

A) Correct. A CT scan is a valuable diagnostic tool to identify the cause and source of bleeding, especially in cases of significant hemorrhage.

B) Incorrect. While a complete blood count (CBC) provides valuable information about the client's red blood cells and hemoglobin levels, it does not directly identify the cause and source of bleeding.

C) Incorrect. An electrocardiogram (ECG) is used to assess the heart's electrical activity and is not relevant to identifying the cause and source of bleeding.

D) Incorrect. Magnetic Resonance Imaging (MRI) is helpful in diagnosing various conditions but is not the primary test for identifying the cause and source of bleeding in a client with suspected hemorrhage.

Questions

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A nurse is caring for a client who experienced external bleeding from a leg wound. Which finding should the nurse recognize as a potential sign of internal bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with liver cirrhosis. Which assessment finding supports the client's increased risk of hemorrhage?

Correct Answer is A

Explanation

A nurse is caring for a client with suspected hemorrhage. The nurse should anticipate which diagnostic test as a priority to identify the cause and source of bleeding?

Correct Answer is A

Explanation

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