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: Telling the client that this is to be expected after surgery is not the first action that the nurse should take, as it may indicate a complication such as increased intraocular pressure, hemorrhage, or infection.
Choice B Reason: Placing the client in a supine position is not the first action that the nurse should take, as it may worsen the pain and increase intraocular pressure.
Choice C Reason: Documenting the findings is not the first action that the nurse should take, as it may delay the intervention and outcome.
Choice D Reason: Notifying the surgeon is the first action that the nurse should take, as it indicates that the client needs immediate evaluation and treatment to prevent vision loss or permanent damage to the eye.
Correct Answer is A
Explanation
Choice A Reason: Buffalo hump and moon face are physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, as they indicate fat redistribution and accumulation due to excess cortisol production.
Choice B Reason: Dry, scaly skin and cold intolerance are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hypothyroidism, which affects the metabolism and skin condition.
Choice C Reason: Dry, sticky mucous membranes and hypovolemia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate dehydration or diabetes insipidus, which affect the fluid balance and urine output.
Choice D Reason: Exophthalmos and tachycardia are not physical assessment findings that the nurse would expect to observe in a client with Cushing's syndrome, but they may indicate hyperthyroidism, which affects the eye protrusion and heart rate.
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