A nurse is caring for a client with suspected internal bleeding. Which assessment finding requires immediate intervention?
Client reports feeling dizzy and lightheaded.
Client's blood pressure is slightly decreased.
Client's skin is pale and cool to the touch.
Client's heart rate is within the normal range.
The Correct Answer is A
A) Correct. Dizziness and lightheadedness are common signs of decreased blood flow, indicating a potential worsening of internal bleeding. Immediate intervention is required to prevent further complications.
B) Incorrect. While a slightly decreased blood pressure could be a concern, it may not be an immediate priority. The nurse should closely monitor the blood pressure and respond promptly if it drops significantly or trends downward.
C) Incorrect. Pale and cool skin may indicate poor perfusion, but it doesn't necessarily require immediate intervention unless it worsens or is accompanied by other alarming signs.
D) Incorrect. Although heart rate can be affected by hemorrhage, being within the normal range doesn't necessarily warrant immediate intervention. Other signs and symptoms should be considered as well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. A CT scan is a valuable diagnostic tool to identify the cause and source of bleeding, especially in cases of significant hemorrhage.
B) Incorrect. While a complete blood count (CBC) provides valuable information about the client's red blood cells and hemoglobin levels, it does not directly identify the cause and source of bleeding.
C) Incorrect. An electrocardiogram (ECG) is used to assess the heart's electrical activity and is not relevant to identifying the cause and source of bleeding.
D) Incorrect. Magnetic Resonance Imaging (MRI) is helpful in diagnosing various conditions but is not the primary test for identifying the cause and source of bleeding in a client with suspected hemorrhage.
Questions
Correct Answer is C
Explanation
A) Incorrect. In DIC, platelet consumption and depletion occur due to widespread clot formation, leading to a decreased platelet count.
B) Incorrect. While inadequate production of clotting factors could lead to bleeding disorders, DIC is characterized by uncontrolled activation of the clotting cascade, leading to excessive clot formation initially, followed by consumption of clotting factors and increased bleeding.
C) Correct. DIC is a serious condition in which there is widespread activation of the clotting cascade, causing the formation of numerous small blood clots throughout the body. These clots can lead to organ dysfunction and excessive bleeding.
D) Incorrect. DIC is associated with decreased platelet count due to the consumption of platelets in the formation of multiple small clots.
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