A nurse is caring for a client with suspected internal bleeding. Which assessment finding requires immediate intervention?
Client reports feeling dizzy and lightheaded.
Client's blood pressure is slightly decreased.
Client's skin is pale and cool to the touch.
Client's heart rate is within the normal range.
The Correct Answer is A
A) Correct. Dizziness and lightheadedness are common signs of decreased blood flow, indicating a potential worsening of internal bleeding. Immediate intervention is required to prevent further complications.
B) Incorrect. While a slightly decreased blood pressure could be a concern, it may not be an immediate priority. The nurse should closely monitor the blood pressure and respond promptly if it drops significantly or trends downward.
C) Incorrect. Pale and cool skin may indicate poor perfusion, but it doesn't necessarily require immediate intervention unless it worsens or is accompanied by other alarming signs.
D) Incorrect. Although heart rate can be affected by hemorrhage, being within the normal range doesn't necessarily warrant immediate intervention. Other signs and symptoms should be considered as well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect. A complete blood count (CBC) provides information about the client's red blood cells, white blood cells, and platelets, but it does not directly assess clotting function.
B) Incorrect. Serum electrolytes help assess the body's fluid balance and various organ functions, but they do not specifically indicate clotting function.
C) Correct. Prothrombin time (PT) is a measure of the time it takes for the blood to clot, primarily assessing the function of the extrinsic pathway of coagulation. It is an essential test in evaluating clotting disorders.
D) Incorrect. Blood glucose level is not directly related to clotting function and is more indicative of a client's metabolic status.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.