The nurse is assessing a patient in the immediate post-operative phase. Which of thr following assessment findings would be most indicative of post-operative hemorrhage?

Stow, shallow respirations and low heart rate

Fever and flushed skin

Disorientation and confusion in an elderly patient

Increasing heart rate and decreasing blood pressure

Answer and Explanation

The Correct Answer is D

A. Slow, shallow respirations and low heart rate:
Slow, shallow respirations and a low heart rate are not typical signs of postoperative hemorrhage. These signs might suggest respiratory or cardiac issues, but they are not specific to hemorrhage. In fact, hemorrhage is more likely to result in tachycardia (increased heart rate) and hypotension (low blood pressure) rather than bradycardia (low heart rate). Therefore, this finding is not indicative of post-operative hemorrhage.

B. Fever and flushed skin:
Fever and flushed skin are more commonly associated with infection rather than hemorrhage. After surgery, fever can be a sign of infection, particularly if it occurs 24-48 hours postoperatively. While infection can sometimes cause a rise in heart rate, it does not directly correlate with the symptoms of hemorrhage. Therefore, fever and flushed skin are not the most indicative of hemorrhage in the immediate postoperative phase.

C. Disorientation and confusion in an elderly patient:
Disorientation and confusion in the elderly post-operative patient can be concerning and may be caused by a variety of factors, such as medication side effects, electrolyte imbalances, or postoperative delirium. While confusion can occur with significant blood loss, it is not a primary indicator of hemorrhage. The signs of hemorrhage are more likely to include changes in vital signs, especially heart rate and blood pressure. Therefore, while disorientation and confusion should be monitored, they are not the most definitive sign of hemorrhage.

D. Increasing heart rate and decreasing blood pressure:
Increasing heart rate (tachycardia) and decreasing blood pressure (hypotension) are classic signs of hemorrhage. When blood loss occurs, the body compensates by increasing the heart rate to maintain cardiac output and attempting to constrict blood vessels. As hemorrhage progresses, blood volume decreases, which leads to a drop in blood pressure. This combination of tachycardia and hypotension is a key indicator of significant blood loss and requires immediate assessment and intervention. Therefore, this is the most indicative finding of postoperative hemorrhage.

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Correct Answer is D

Explanation

A. 2+ pedal edema bilaterally:
While 2+ pedal edema (a mild level of swelling in the feet and ankles) is concerning, it is not an immediate emergency in the context of hyponatremia. Edema can be seen in various conditions, including fluid retention associated with hyponatremia, but it does not require urgent intervention unless it is severe or worsening. This finding would warrant monitoring but does not require immediate action.

B. Blood pressure at 107/82:
A blood pressure reading of 107/82 mmHg is within normal limits, although on the lower end of the spectrum. This is not a concerning finding in this case and does not suggest a need for immediate intervention. The nurse should continue to monitor the client, but this blood pressure reading alone is not an emergency.
C. Urine output of 460 mL in 24 hours:
A urine output of 460 mL in 24 hours is low, indicating oliguria (decreased urine output), which can occur in cases of hyponatremia due to fluid retention. However, unless the urine output is worsening or associated with other signs of acute kidney injury or severe fluid overload, this finding alone does not require immediate intervention. It is something that should be monitored and further investigated.

D. Disorientation:
Disorientation in the elderly client with hyponatremia is a critical finding that requires immediate intervention. Hyponatremia can lead to cerebral edema (brain swelling), which results in altered mental status, including confusion, disorientation, or seizures. These symptoms indicate that the hyponatremia may be severe enough to affect neurological function and requires prompt correction to avoid further complications, such as coma or permanent brain damage. Immediate intervention to address the underlying cause of the hyponatremia and restore sodium balance is crucial.

A. The blockage is most likely in the right parietal region B. This type of event can be one of the primary warning sign of a future stroke C. The signs and symptoms are most consistent with an acute hemorrhagic stroke D. The signs and symptoms are most consistent with a focal awareness seizure.

Correct Answer is B

Explanation

A. The blockage is most likely in the right parietal region:
While a facial droop and weakness can be indicative of a stroke, the specific location of the blockage cannot be definitively determined based on the symptoms alone. A right-sided facial droop suggests that the lesion or event likely involves the left side of the brain, particularly the frontal or temporal regions, as these areas are typically associated with facial motor control. A parietal lesion would more commonly result in sensory deficits or spatial issues, not primarily facial droop. Therefore, this statement is not correct in this case.

B. This type of event can be one of the primary warning signs of a future stroke:
The client’s presentation of unilateral facial droop and weakness that resolves spontaneously within an hour is highly consistent with a transient ischemic attack (TIA). A TIA, often referred to as a "mini-stroke," is characterized by temporary neurological deficits that resolve without permanent damage. TIAs are considered warning signs of a potential future stroke, and the client should be evaluated promptly to address risk factors and prevent a more serious, permanent stroke.

C. The signs and symptoms are most consistent with an acute hemorrhagic stroke:
An acute hemorrhagic stroke typically presents with sudden and severe neurological deficits, such as a severe headache, vomiting, and loss of consciousness. Hemorrhagic strokes do not typically resolve spontaneously within an hour. The client's symptoms (unilateral facial droop and weakness that resolve within an hour) are more indicative of a TIA, not a hemorrhagic stroke. A hemorrhagic stroke would likely result in sustained deficits and a more urgent clinical presentation.

D. The signs and symptoms are most consistent with a focal awareness seizure:
Focal awareness seizures (previously known as simple partial seizures) generally involve abnormal electrical activity in a specific area of the brain, leading to symptoms such as motor twitches or sensory disturbances, but not typically a full facial droop or weakness. These seizures do not cause symptoms that resolve in such a short time, nor do they present with unilateral weakness in the manner described here. Therefore, this scenario is not consistent with a seizure disorder.

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The nurse is assessing a patient in the immediate post-operative phase. Which of thr following assessment findings would be most indicative of post-operative hemorrhage?

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