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 C
Explanation
A) Incorrect. While ambulation is important for overall health, it is not the priority action to prevent bleeding complications.
B) Incorrect. Prophylactic antibiotics may be prescribed for specific medical conditions but are not the primary intervention to prevent hemorrhage.
C) Correct. Applying pressure dressings to potential bleeding sites is the priority action to prevent or control bleeding. It helps promote hemostasis and reduces the risk of excessive bleeding.
D) Incorrect. Monitoring blood glucose levels is important for clients with diabetes but is not directly related to preventing hemorrhage.
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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