A nurse is caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?

Temperature of 38° C (100.4° F)

Respiratory rate of 10/min

Heart rate of 112/min

Blood pressure of 136/88 mm Hg

Answer and Explanation

The Correct Answer is C

A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.

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Correct Answer is A

Explanation

A. Translucent, red tissue Granulation tissue is red or pink due to increased blood supply and is a sign of healing.
B. Soft, yellow tissue This describes slough, which consists of dead tissue and debris that may delay wound healing.
C. Stringy, white tissue This could indicate fibrin or slough, which may require debridement.
D. Thick, black tissue This describes eschar, which is necrotic (dead) tissue and needs removal for proper wound healing.

A. Instruct the client to take small sips of water. B. Ask the client to hyperextend their neck during palpation. C. Inspect the isthmus as the client holds their breath for 5 seconds. D. Assist the client to a supine position prior to the assessment.

Correct Answer is A

Explanation

A. "Instruct the client to take small sips of water."
Having the client take small sips of water helps the nurse observe the thyroid gland as it moves up and down with swallowing, making abnormalities more noticeable.
B. "Ask the client to hyperextend their neck during palpation."
The client should slightly extend (not hyperextend) their neck to relax the muscles and allow for better palpation of the thyroid gland.
C. "Inspect the isthmus as the client holds their breath for 5 seconds."
The thyroid gland is best observed during swallowing, not by holding the breath.
D. "Assist the client to a supine position prior to the assessment."
Thyroid assessment is performed with the client in a sitting or standing position, not lying down.

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A nurse is caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?

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