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 C
Explanation
A. Initiate intravenous (IV) access for fluid replacement. This is important for managing shock or significant blood loss, but it is not the first priority in managing severe bleeding.
B. Place the client's arm in a dependent position. This would not be appropriate for severe bleeding and does not control hemorrhage effectively.
C. Apply pressure directly to the wound. This is correct. Direct pressure is the immediate and essential step to control bleeding in a severe wound. It helps to stabilize the clot and reduce blood loss.
D. Apply a tourniquet just below the level of the shoulder. This is not the first intervention. A tourniquet is used if direct pressure does not control severe bleeding and should be applied above the wound, not below.
Correct Answer is D
Explanation
A. Instruct the client to abstain from sexual intercourse for 24 hours prior to the test: While abstaining from sexual intercourse can be recommended to avoid contamination, it is not the most immediate concern before performing the test.
B. Educate the client about the risk factors associated with cervical cancer: While important, this is not a pre-procedural intervention but rather part of general patient education.
C. Assess the client's vital signs, including blood pressure and pulse rate: Vital signs are important but not specifically required before performing a Pap test.
D. Explain the steps of the Pap test procedure to the client: This is the most appropriate intervention as it prepares the client for the procedure, reducing anxiety and ensuring informed consent.
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