A nurse is collecting data from a client diagnosed with laryngeal cancer who is postoperative following a laryngectomy. Which of the following is a clinical manifestation of a hemorrhage?
Increased pain
Continuous swallowing
Poor fluid intake
Drooling
The Correct Answer is B
Choice A Reason: Increased pain is not a specific sign of hemorrhage, but it may indicate inflammation, infection, or nerve damage.
Choice B Reason: Continuous swallowing is a sign of hemorrhage, as it indicates that blood is accumulating in the throat or esophagus and stimulating the swallowing reflex.
Choice C Reason: Poor fluid intake is not a sign of hemorrhage, but it may indicate difficulty swallowing, nausea, or dehydration.
Choice D Reason: Drooling is not a sign of hemorrhage, but it may indicate impaired oral control, salivary gland damage, or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Administering antispasmodic medications is not the first action that the nurse should perform, as it may not resolve the problem of urinary output or irrigation flow.
Choice B Reason: Notifying the provider is not the first action that the nurse should perform, as it may delay the intervention and worsen the outcome.
Choice C Reason: Offering oral fluids is not the first action that the nurse should perform, as it may increase fluid overload or bladder pressure.
Choice D Reason: Determining the patency of the tubing is the first action that the nurse should perform, as it may identify and correct any obstruction or kinking that prevents urinary output or irrigation flow.
Correct Answer is D
Explanation
Choice A Reason: Ketoacidosis is not likely to be the complication that the nurse should suspect, as it is caused by high blood glucose levels and results in symptoms such as nausea, vomiting, abdominal pain, fruity breath, and deep breathing.
Choice B Reason: Hyperglycemia is not likely to be the complication that the nurse should suspect, as it is caused by high blood glucose levels and results in symptoms such as thirst, polyuria, blurred vision, dry skin, and fatigue.
Choice C Reason: Nephropathy is not likely to be the complication that the nurse should suspect, as it is a chronic kidney disease that develops over time due to diabetes and results in symptoms such as proteinuria, edema, hypertension, and anemia.
Choice D Reason: Hypoglycemia is likely to be the complication that the nurse should suspect, as it is caused by low blood glucose levels and results in symptoms such as sweating, tachycardia, lightheadedness, shakiness, hunger, and confusion.
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