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

Answer and Explanation

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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Correct Answer is C

Explanation

A.Factor X is a clotting factor involved in the coagulation cascade. It is not directly related to preventing infections. While clotting factors are essential for hemostasis, they do not play a role in infection prevention.

B. Steroids can suppress the immune response, making the child more susceptible to infections. Therefore, they are not specifically administered to prevent infections

C. In a child with a sickle cell crisis who is hospitalized, preventing infections is crucial due to the increased risk of infections in this condition. Administering immunizations that the patient is scheduled for can help prevent certain infections.

Children with sickle cell disease are at a higher risk of bacterial infections, especially from encapsulated organisms like Streptococcus pneumoniae and Haemophilus influenzae. Vaccines can help protect against these pathogens and reduce the risk of serious infections.

Some of the recommended immunizations for children with sickle cell disease include:

Pneumococcal vaccine: This helps protect against infections caused by Streptococcus pneumoniae, which can cause severe respiratory and bloodstream infections.

Haemophilus influenzae type B (Hib) vaccine: This protects against infections caused by Haemophilus influenzae type B, which can lead to serious illnesses like pneumonia and meningitis.

Meningococcal vaccine: This protects against Neisseria meningitidis, which can cause meningitis and bloodstream infections.

Influenza vaccine: This annual vaccine helps protect against seasonal flu, which can be severe in children with sickle cell disease.

Administering these vaccines according to the recommended schedule helps provide protection against certain infections and can improve outcomes for children with sickle cell disease during hospitalization and beyond. The other options, Factor X, steroids, and PCA morphine, are not specific measures for preventing infections in a child with sickle cell crisis.

D.PCA (patient-controlled analgesia) morphine is used for pain management during a sickle cell crisis. It does not directly prevent infections.

A. Irritability B. Tetany C. slow, bounding pulse D. Decreased temperature

Correct Answer is A

Explanation

The nurse should expect to find irritability in an infant who is dehydrated. Dehydration in infants can lead to changes in behavior and irritability due to the imbalance in fluid and electrolytes. Other common signs of dehydration in infants may include:
Poor skin turgor (skin tenting)
Sunken fontanelles (soft spots on the baby's head)
Dry mucous membranes (dry mouth and tongue)
Decreased urine output or concentrated urine
Rapid heart rate (tachycardia)
Increased respiratory rate
Sunken eyes
Decreased tears when crying

B. Tetany is a condition characterized by involuntary muscle contractions and is more commonly associated with hypocalcemia (low calcium levels) rather than dehydration.
C. A slow, bounding pulse is not typically associated with dehydration. Dehydration often leads to a rapid heart rate (tachycardia) as the body attempts to compensate for the loss of fluid.
D. Decreased temperature is not a typical finding in dehydration. Dehydration can lead to fever in some cases due to an underlying infection, but it does not cause a decrease in body temperature on its own.

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A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

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d

Correct Answer is C

Explanation

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Correct Answer is A

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