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A nurse is caring for an adult client after a fall. Which of the following assessment findings indicates the client may be bleeding internally?

A.

Temperature of 38° C (100.4° F)

B.

Respiratory rate of 10/min

C.

Heart rate of 112/min

D.

Blood pressure of 136/88 mm Hg

Answer and Explanation

The Correct Answer is C

A. Temperature of 38° C (100.4° F) A slight fever is not a primary sign of internal bleeding. It could be related to infection or another inflammatory response.
B. Respiratory rate of 10/min Internal bleeding is more likely to cause an increased respiratory rate (tachypnea) due to hypoxia rather than a decreased rate.
C. Heart rate of 112/min Tachycardia (HR >100 bpm) is an early sign of internal bleeding. The body increases the heart rate to compensate for blood loss and maintain perfusion.
D. Blood pressure of 136/88 mm Hg While low blood pressure (hypotension) can indicate severe internal bleeding, this BP is within normal range. However, a sudden drop in BP later would be a concerning sign.


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Related Questions

Correct Answer is B,C,E,A,D

Explanation

  1. Assist the client into a sitting position in a chair. Ensures comfort and stability before starting foot care.
  2. Soak the client's feet in warm water. Softens the skin and makes cleaning easier.
  3. Rub callused areas of the client's feet using a washcloth. Helps remove dead skin and promotes circulation.
  4. Gently dry the client's feet and areas between the toes with a towel. Prevents moisture buildup, which can lead to fungal infections.
  5. Apply lotion to the client's feet. Moisturizes the skin but should not be applied between the toes to prevent excessive moisture retention and fungal growth.

Correct Answer is D

Explanation

A. "Submitting an incident report to risk management following a client fall." While this is important for safety and quality improvement, it is not a direct act of client advocacy.
B. "Documenting the effectiveness of pain medication in the client's health record." This is a critical part of nursing documentation but does not actively advocate for the client.
C. "Asking another nurse to check a medication calculation for a client." This promotes medication safety, but it is not an example of client advocacy.
D. "Informing the family of a deceased client of the client's wish to be an organ donor." Advocacy means ensuring the client’s wishes are honored, especially in sensitive situations like organ donation.

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