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. A client who has an open upper extremity fracture: While this is a serious injury, it is less critical compared to a tension pneumothorax in a triage setting.
B. A client experiencing a tension pneumothorax: This is a life-threatening condition that requires immediate intervention to relieve pressure on the lungs and restore adequate breathing.
C. A client who has full-thickness burns over 85% of their body: This is a severe condition with a high mortality risk, but in a mass casualty situation, a tension pneumothorax is prioritized for immediate care.
D. A client who has agonal respirations: Agonal respirations indicate severe distress, but the immediate need for intervention is to address conditions that can rapidly compromise life, such as a tension pneumothorax.

A. History of sexually transmitted infection (STI) B. History of breast cancer C. History of chronic obstructive pulmonary disease (COPD) D. History of thyroiditis

Correct Answer is B

Explanation

A. History of sexually transmitted infection (STI): This is incorrect. A history of STI is not a contraindication for menopausal hormone therapy.
B. History of breast cancer: This is correct. Hormone therapy is not recommended for individuals with a history of breast cancer due to the potential risk of cancer recurrence or progression.
C. History of chronic obstructive pulmonary disease (COPD): This is incorrect. While HT might not be the primary treatment for COPD, it is not contraindicated solely due to COPD.
D. History of thyroiditis: This is incorrect. A history of thyroiditis does not contraindicate the use of hormone therapy for menopause.

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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

A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?

Correct Answer is B

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Correct Answer is B

Explanation

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