A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

Bradycardia

Increased blood pressure

Warm, flushed skin

Decreased urine output

Answer and Explanation

The Correct Answer is B

A) Incorrect. Bradycardia is not typically an early sign of compensatory response to hypovolemia. The body often responds to hypovolemia with an increased heart rate (tachycardia).

B) Correct. In the early stages of hypovolemia, the body may attempt to compensate by increasing blood pressure to maintain perfusion to vital organs.

C) Incorrect. Warm, flushed skin may be present in the initial stages of hypovolemia, but it is not necessarily an early sign of compensatory response.

D) Incorrect. Decreased urine output is a later sign of hypovolemia when the body's compensatory mechanisms are no longer effective in maintaining blood flow to the kidneys.

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Correct Answer is B

Explanation

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.

Questions

A. Excessive production of platelets. B. Inadequate production of clotting factors. C. Uncontrolled activation of the clotting cascade. D. Decreased platelet count.

Correct Answer is C

Explanation

A) Incorrect. In DIC, platelet consumption and depletion occur due to widespread clot formation, leading to a decreased platelet count.

B) Incorrect. While inadequate production of clotting factors could lead to bleeding disorders, DIC is characterized by uncontrolled activation of the clotting cascade, leading to excessive clot formation initially, followed by consumption of clotting factors and increased bleeding.

C) Correct. DIC is a serious condition in which there is widespread activation of the clotting cascade, causing the formation of numerous small blood clots throughout the body. These clots can lead to organ dysfunction and excessive bleeding.

D) Incorrect. DIC is associated with decreased platelet count due to the consumption of platelets in the formation of multiple small clots.

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A client is brought to the emergency department with suspected internal bleeding. Which assessment finding would the nurse identify as an early sign of compensatory response to hypovolemia?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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