A nurse is assessing a client who experienced a significant hemorrhage. Which clinical manifestation should the nurse expect to find during the early stages of hemorrhage?
Bradycardia
Hypotension
Pallor
Restlessness
The Correct Answer is D
A) Incorrect. Bradycardia is not typically an early clinical manifestation of hemorrhage. The body may initially compensate for the blood loss by increasing heart rate (tachycardia).
B) Incorrect. Hypotension may occur later in the course of hemorrhage as blood loss progresses, but it is not an early manifestation.
C) Incorrect. Pallor (pale skin) may occur later as a result of decreased blood volume, but it is not an early sign.
D) Correct. Restlessness and anxiety are early manifestations of hemorrhage, reflecting the body's compensatory response to maintain perfusion in the early stages of blood loss.
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Related Questions
Correct Answer is C
Explanation
A) Incorrect. While a complete blood count (CBC) provides valuable information about the client's red blood cell count and hemoglobin levels, it does not directly confirm the presence of bleeding or assess the clotting function.
B) Incorrect. Magnetic Resonance Imaging (MRI) is a valuable tool for diagnosing various conditions but is not a primary test for confirming the presence of bleeding.
C) Correct. A coagulation panel, which includes prothrombin time (PT) and activated partial thromboplastin time (PTT), helps assess the clotting function and can aid in confirming the presence of bleeding and identifying coagulation disorders.
D) Incorrect. Fecal Occult Blood Test (FOBT) is used to detect hidden blood in stool, which is indicative of lower gastrointestinal bleeding, but it does not confirm internal bleeding in other areas of the body.
Correct Answer is B
Explanation
A) Incorrect. Checking the client's blood pressure is important but not the most critical action before starting a blood transfusion.
B) Correct. The most crucial step before administering any intervention, including a blood transfusion, is to verify the client's identification using two identifiers (e.g., name and date of birth or medical record number) to ensure the right blood is given to the right client.
C) Incorrect. While assessing the client's oxygen saturation is important, it is not the priority before starting a blood transfusion.
D) Incorrect. Obtaining consent for the blood transfusion is essential, but verifying the client's identification is more critical before administering the transfusion.
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