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 B

Explanation

A. Community law enforcement officers can serve as triage officials during an emergency: Law enforcement officers are typically not trained as triage officials and their primary role is to ensure public safety and manage security.
B. Nurses and other emergency medical personnel can serve as triage officials during an emergency: This is correct as nurses and other trained medical personnel have the necessary skills to assess and prioritize care based on the severity of injuries or conditions.
C. Local fire fighters can serve as triage officials during an emergency: While fire fighters are crucial in emergency response, they are not typically trained as triage officers unless they have specific medical training.
D. Members of the Federal Emergency Management Agency (FEMA) can serve as triage officials during an emergency: FEMA provides support and resources but does not generally serve as triage officials. The role of triage is typically handled by medical professionals on the scene.

A. Instruct the client to change clothing before arriving. B. Inform the client that photographs of any injuries will be mandatory for a police report. C. Ask the client to repeat the information obtained during admission. D. Obtain a history of the incident from the client.

Correct Answer is D

Explanation

A. Instruct the client to change clothing before arriving: This is incorrect. The client should keep the clothing worn during the assault as it may contain crucial evidence.
B. Inform the client that photographs of any injuries will be mandatory for a police report: This is incorrect. While evidence collection is important, it should be done with the client’s consent and consideration of their emotional state.
C. Ask the client to repeat the information obtained during admission: This is incorrect. Asking the client to repeat information can be traumatic. The history should be obtained sensitively and only as needed.
D. Obtain a history of the incident from the client: This is correct. The nurse needs to gather information to provide appropriate care and ensure evidence is collected properly. This should be done in a supportive and respectful manner.

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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

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