A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?
Respiratory rate 20/min
Abdominal pain rated 4 on a scale of 0 to 10
Heart rate 72/min
Blood pressure 92/50 mm Hg
The Correct Answer is D
The nurse's priority assessment finding in an adolescent who experienced blunt trauma to the abdomen is low blood pressure (hypotension). Hypotension could indicate significant internal bleeding or hemorrhage, which is a life-threatening condition and requires immediate attention. The decreased blood pressure may be a sign of shock, and prompt intervention is needed to stabilize the client's condition and prevent further deterioration.
While all the other findings (respiratory rate, abdominal pain, and heart rate) are important and should be assessed and monitored, blood pressure is the most critical in this situation due to its potential association with severe internal injuries and the risk of hypovolemic shock.
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Related Questions
Correct Answer is C
Explanation
In an infant with a history of vomiting and fever, body weight is the most reliable indicator of fluid loss. Monitoring the infant's weight over time can help assess the degree of dehydration and guide the appropriate fluid replacement therapy. A significant decrease in body weight suggests significant fluid loss.
Option A: Skin integrity is important to assess for signs of dehydration, but it is not as reliable as body weight in determining the extent of fluid loss.
Option B: Respiratory rate can be affected by various factors and is not a direct indicator of fluid loss.
Option D: Blood pressure is not the most reliable indicator of fluid loss in an infant with dehydration. In severe cases of dehydration, blood pressure can drop, but it is not as sensitive as body weight in assessing the extent of fluid loss.
Correct Answer is C
Explanation
Severe anemia is a condition characterized by a significant decrease in the number of red blood cells or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. This can result in fatigue, weakness, and shortness of breath in the affected individual.
A red blood cell transfusion is given to a child with severe anemia to increase the number of red blood cells and, consequently, the hemoglobin level in the blood. This helps improve oxygen delivery to tissues and organs, which can lead to increased energy levels and reduced fatigue.
Option A is incorrect because red blood cell transfusion is not given to help the body stop bleeding by forming a clot. Platelets are responsible for clot formation, not red blood cells.
Option B is incorrect because a red blood cell transfusion is not used to fight infections. White blood cells and the immune system are responsible for fighting infections.
Option D is incorrect because a red blood cell transfusion is not given to allow her parents to come to visit her. Transfusions are medical treatments to address specific medical conditions and are not related to visitation rights.
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