A nurse is caring for a client with a suspected bleeding disorder. Which nursing assessment is most essential to identify potential bleeding sources?

Neurological assessment

Skin integrity assessment

Abdominal assessment

Respiratory assessment

Answer and Explanation

The Correct Answer is B

A) Incorrect. A neurological assessment is important to evaluate the client's central nervous system function, but it is not directly related to identifying bleeding sources.

B) Correct. A skin integrity assessment is essential to identify potential external bleeding sources, such as cuts, bruises, or petechiae, which may indicate underlying bleeding disorders.

C) Incorrect. While an abdominal assessment is crucial in identifying internal bleeding in the abdominal area, it is not the most essential assessment to identify bleeding sources overall.

D) Incorrect. A respiratory assessment is important for assessing oxygenation and respiratory status, but it is not the primary assessment to identify bleeding sources.

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Correct Answer is D

Explanation

A) Incorrect. Hemoglobin levels may initially be normal or slightly decreased, but they would decrease later due to the body's compensatory response to dilute the remaining blood.

B) Incorrect. Platelet count may not be significantly affected in the early stages of hemorrhage. It is mainly responsible for clot formation, which becomes more relevant in the later stages.

C) Incorrect. In the early stages of hemorrhage, the white blood cell count is not significantly affected. It plays a role in fighting infection and inflammation.

D) Correct. Hematocrit levels represent the proportion of red blood cells in the blood. During early stages of hemorrhage, there is a loss of red blood cells, leading to decreased hematocrit levels.

A. Hypertension B. Bradycardia C. Tachypnea D. Hyperthermia

Correct Answer is C

Explanation

A. Hypertension is not an early sign of hemorrhage; instead, hypotension occurs as blood loss progresses.
B. Bradycardia is not an expected response; tachycardia is more common due to compensatory mechanisms.
C. Tachypnea is an early indicator of internal bleeding as the body attempts to compensate for decreased oxygen delivery by increasing respiratory rate.
D. Hyperthermia is not associated with hemorrhage; instead, hypothermia can occur with significant blood loss.

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A nurse is caring for a client with a suspected bleeding disorder. Which nursing assessment is most essential to identify potential bleeding sources?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is C

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