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 A
Explanation
A) Correct. Increasing consumption of vitamin C-rich foods can enhance iron absorption, which is essential for replenishing iron stores in clients at risk of anemia due to hemorrhage.
B) Incorrect. Red meat and poultry products are good sources of heme iron, which is highly absorbable and beneficial for individuals at risk of anemia.
C) Incorrect. Leafy green vegetables are excellent sources of non-heme iron, which is also essential for iron intake in the diet.
D) Incorrect. Dairy products do not significantly impact iron intake and can be included in the diet unless the client has specific dietary restrictions.
Correct Answer is B
Explanation
A) Incorrect. Acute blood loss does not typically lead to a decreased platelet count. Platelet levels may remain within the normal range or slightly decrease due to hemodilution.
B) Correct. In acute blood loss, the concentration of red blood cells decreases, leading to hemoconcentration and elevated hemoglobin levels. This is the body's initial response to conserve oxygen-carrying capacity.
C) Incorrect. An increased white blood cell count is not a direct result of acute blood loss and may indicate other inflammatory or infectious processes.
D) Incorrect. Elevated liver enzymes are not a typical finding in acute blood loss. They are more indicative of liver injury or dysfunction.
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