A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:
restlessness, rising pulse, and falling blood pressure.
lethargy, falling pulse, and rising blood pressure.
headache, rising pulse, and falling blood pressure.
restlessness, falling pulse, and rising blood pressure.
The Correct Answer is A
Choice A rationale:
Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.
Choice B rationale:
Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Choice C rationale:
Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.
Choice D rationale:
Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.
Choice B rationale:
Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.
Choice C rationale:
Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.
Choice D rationale:
Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.
Correct Answer is C
Explanation
Choice A rationale:
Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.
Choice B rationale:
Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.
Choice C rationale:
Stage 1 pressure injuries are characterized by intact skin with localized erythema.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.
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