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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Applying a warm compress may promote vasodilation and increase bleeding in the joint. It is not recommended for managing joint bleeding in a client with hemophilia.
B) Correct. The priority intervention for managing joint bleeding in a client with hemophilia is to administer prescribed clotting factor replacement therapy to promote clot formation and stop the bleeding.
C) Incorrect. Elevating the affected joint can help reduce swelling, but it is not the priority intervention when the client is experiencing an acute joint bleed.
D) Incorrect. Encouraging active range of motion exercises can worsen joint bleeding and is contraindicated in a client with acute joint bleeding due to hemophilia.
Questions
Correct Answer is B
Explanation
A) Incorrect. While hypertension can be a risk factor for cardiovascular issues, it is not directly associated with an increased risk of hemorrhage.
B) Correct. Anticoagulant medication can interfere with the body's clotting mechanisms, making the client more susceptible to bleeding and hemorrhage.
C) Incorrect. Being a regular blood donor does not inherently increase the risk of hemorrhage unless the client donates too frequently, leading to anemia.
D) Incorrect. Having a balanced diet is essential for overall health, but it is not a specific risk factor for hemorrhage.
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