A client with multiple injuries to the head, chest, and abdomen has had their airway stabilized and is breathing on their own. Which symptom would lead the nurse to suspect internal hemorrhaging even when the nurse does not see any bleeding?
Increased sweating
Increased redness at the site
Increased abdominal distention
Increased blood pressure
The Correct Answer is C
A. Increased sweating: This is incorrect. Increased sweating is not typically indicative of internal hemorrhaging. It can be associated with various conditions but is not a specific sign of internal bleeding.
B. Increased redness at the site: This is incorrect. Increased redness would more likely be associated with localized infection or inflammation rather than internal hemorrhaging.
C. Increased abdominal distention: This is correct. Increased abdominal distention can be a sign of internal hemorrhaging, particularly if blood accumulates in the abdominal cavity (hemoperitoneum), leading to abdominal swelling and discomfort.
D. Increased blood pressure: This is incorrect. Internal hemorrhaging often leads to hypotension rather than increased blood pressure, as blood volume decreases and the body attempts to compensate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Flu-like symptoms: This is correct. Inhalation anthrax initially presents with flu-like symptoms, including fever, cough, and malaise. This early presentation can progress to severe respiratory distress and systemic illness.
B. Vesicles on the skin: This is incorrect. Vesicular lesions are more characteristic of diseases such as smallpox or chickenpox, not anthrax.
C. Respiratory failure: While respiratory failure can occur with advanced inhalation anthrax, it is a later-stage complication rather than an initial finding.
D. Flaccid paralysis: This is incorrect. Flaccid paralysis is not a typical symptom of anthrax exposure but may be associated with diseases such as botulism.
Correct Answer is C
Explanation
A. Allow a drinking glass on the client's meal tray: This is incorrect. Allowing objects that could potentially be used for self-harm is unsafe. All items on the client's meal tray should be carefully reviewed to ensure they do not pose a risk.
B. Place the client in four-point restraints: This is incorrect. Restraints are used as a last resort and should only be applied following a thorough assessment of the client's needs and risks, considering less restrictive measures first.
C. Inspect the client's personal belongings: This is correct. Inspecting personal belongings is crucial to ensure that the client does not have items that could be used for self-harm. This step helps in identifying and removing potential hazards.
D. Assign the client to a private room: This is incorrect. Assigning a client to a private room might not be appropriate as it could isolate the client and reduce opportunities for observation and intervention. A safer approach is to place the client in a room where they can be closely monitored, typically a shared room with staff supervision.
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