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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Following a cardiac catheterization, the nurse should provide the parent with appropriate discharge instructions to ensure the child's proper recovery. The correct instruction to include is option B: "Give the child acetaminophen for discomfort."
Explanation:
Option A: Offering the child clear liquids for the first 24 hours is not a typical instruction following a cardiac catheterization. After the procedure, the child may be allowed to resume a regular diet, as tolerated, based on the healthcare provider's orders.
Option B: This is the correct instruction. After cardiac catheterization, the child may experience some discomfort at the insertion site or the area where the catheter was threaded through the blood vessels. Acetaminophen can be used to manage mild pain or discomfort.
Option C: Taking a tub bath for the first 3 days is not typically mentioned in discharge instructions after a cardiac catheterization. The nurse might advise the parent to avoid submerging the catheter insertion site in water for a specific period and instead use sponge baths until permitted by the healthcare provider.
Option D: Keeping the child home for 1 week is not a standard recommendation for a cardiac catheterization. The recovery period after a cardiac catheterization is usually shorter, and the child can often resume normal activities within a day or two, depending on the specific circumstances of the procedure and the child's condition.
The nurse should thoroughly review the specific discharge instructions provided by the healthcare provider and ensure the parent understands the care required at home, including any restrictions on activities or signs of potential complications that require immediate attention.
Correct Answer is B
Explanation
During a sickle cell crisis, the child experiences severe pain due to the sickled red blood cells blocking blood flow in the vessels, leading to tissue ischemia and infarction. Pain is the hallmark symptom of sickle cell crisis and can occur in various parts of the body, such as the abdomen, chest, back, joints, and extremities.
A. Constipation is not a common symptom of sickle cell crisis. It may be associated with other conditions but is not directly related to sickle cell crisis.
C. High fever is not a typical finding in sickle cell crisis. Fever may occur due to infections, which individuals with sickle cell disease are at increased risk of developing, but it is not a direct symptom of the crisis itself.
D. Bradycardia (slow heart rate) is not commonly associated with sickle cell crisis. Tachycardia (rapid heart rate) may occur in response to pain, but bradycardia is not a typical finding.
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