Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply.

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The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension. Black stools (melena) indicates slow upper gastrointestinal bleeding; tachycardia may indicate significant blood loss. Therefore, this client needs immediate assessment. (Option B) This change in vital signs from preprocedure to postprocedure most likely reflects decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not produce bleeding serious enough to make a client hypotensive. If this client was bleeding, it would compress the spinal cord, causing paralysis in the lower extremities. (Option C) This client has a pulse of 62/min (normal 60-100/min), which indicates a therapeutic effect of metoprolol. The nurse should monitor for bradycardia, which is a common and expected finding following administration of a beta-adrenergic blocker. Bradycardia would require nursing intervention only if the client became symptomatic (eg, hypotension, dizziness, nausea). (Option E) A neonate's resting pulse is 110-160/min. Crying or vigorous kicking can cause a temporary rise. Vital signs are concerning if they rise when a client is at rest. Educational objective: Vital sign changes that are early signs of concern for hypovolemic shock are tachypnea, tachycardia, and agitation; hypotension is a late finding.

Which Client Condition Is Concerning and Requires Further Nursing Assessment