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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "I can detect the presence of carbon monoxide by a metallic odor." This is incorrect. Carbon monoxide is odorless, colorless, and tasteless, making it undetectable by smell.
B. "A high concentration of carbon monoxide can cause unconsciousness." This is correct. High levels of carbon monoxide can lead to serious symptoms including loss of consciousness.
C. "Breathing in carbon monoxide can cause headaches and nausea." This is correct. Symptoms of carbon monoxide poisoning include headaches, nausea, and dizziness.
D. "Leaky gas or oil furnaces can cause carbon monoxide poisoning." This is correct. Faulty or leaky heating systems can be a source of carbon monoxide exposure.

A. A client who has a fractured fibula and tibia B. A client who has sustained a major burn to their upper torso and extremities C. A client who has a sprained ankle and laceration to the lower leg D. A client who has an open traumatic brain injury and agonal breaths

Correct Answer is D

Explanation

A. A client who has a fractured fibula and tibia: This is incorrect. While serious, this injury does not require immediate life-saving intervention and is generally categorized as less urgent.
B. A client who has sustained a major burn to their upper torso and extremities: This is incorrect. Although severe, if the client is stable and responsive, they may be categorized as yellow (delayed) unless there are immediate life-threatening complications.
C. A client who has a sprained ankle and laceration to the lower leg: This is incorrect. These injuries are considered less severe and would typically be tagged as green (minor).
D. A client who has an open traumatic brain injury and agonal breaths: This is correct. Agonal breaths and severe head injury indicate a need for immediate life-saving intervention, so this client should receive a red tag for the highest priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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