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. Electric razors are safer than traditional razors because they reduce the risk of cuts and bleeding in clients with bleeding disorders.
B) Incorrect. Adequate hydration is essential for overall health, and limiting fluid intake is not recommended for clients with bleeding disorders.
C) Incorrect. High-impact exercises can increase the risk of injury and bleeding in clients with bleeding disorders. Low-impact exercises are preferable.
D) Incorrect. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding and should be avoided by clients with bleeding disorders.
Correct Answer is A
Explanation
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.
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