The nurse suspects that a client who presented to the emergency department is experiencing bleeding from liver trauma, Which cues support the nurse's suspicion? Select all that apply.

Rationale: A. New onset of lightheadedness is a key sign of hypovolemia due to internal bleeding. Blood loss decreases circulating volume, leading to decreased perfusion to the brain and dizziness or syncope. This supports the suspicion of internal hemorrhage from liver trauma. B. Complaints of right shoulder pain (Kehr’s sign) can indicate referred pain from diaphragmatic irritation due to blood in the peritoneal cavity, commonly associated with liver or spleen trauma. This is an important clinical cue supporting internal bleeding. C. Heart rate of 116 beats per minute indicates tachycardia, a compensatory response to hypovolemia. The body increases heart rate to maintain cardiac output when blood volume decreases, which is consistent with bleeding. D. Requesting more water to drink is not directly related to liver trauma or internal bleeding. While thirst may occur with mild fluid loss, it is nonspecific and not a reliable cue for acute hemorrhage. E. A wide pulse pressure (the difference between systolic and diastolic BP) is not typically associated with acute hemorrhage. In early blood loss, blood pressure is often normal or low-normal, and pulse pressure may narrow, not widen. F. Respiratory rate of 28 breaths per minute indicates tachypnea, which can occur as a compensatory mechanism for hypovolemia and tissue hypoxia. Increased respiratory rate helps improve oxygen delivery when perfusion is compromised due to bleeding.