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 A
Explanation
The nurse should recommend bananas as a safe food choice for a 2-year-old child. Bananas are soft and easy to chew, making them safe for young children. They do not pose a choking hazard, unlike grapes, raw carrots, or celery.
Option B (Grapes) can be a choking hazard for young children, especially if they are not cut into small pieces or are given whole.
Option C (Raw carrots) and Option D (Celery) are hard and crunchy, and they require more chewing, which may not be safe for a 2-year-old child who is still developing their chewing and swallowing abilities.
As a general guideline, when selecting foods for young children, it is essential to choose soft, easily chewable, and non-choking hazard options to promote safe eating and reduce the risk of choking incidents.
Correct Answer is C
Explanation
Rheumatic fever (RF) is a complication that can occur after an untreated or inadequately treated streptococcal throat infection (strep throat). It can affect the heart, joints, skin, and brain. One important aspect of managing RF is to prevent further episodes of strep throat, as it can trigger recurrent RF. Therefore, the child with a history of RF will require prophylactic antibiotics (usually penicillin or a related antibiotic) before certain invasive procedures, dental work, or surgeries to prevent strep throat and subsequent recurrence of RF.
Option A is not specific to rheumatic fever, and while electrolyte imbalances may be monitored and managed in certain cases of severe illness, it is not a core aspect of managing RF.
Option B is not accurate. While many children with RF do recover fully with appropriate treatment, they may be at risk of developing rheumatic heart disease, which can lead to long-term complications if not managed properly.
Option D is not a direct implication of RF. Rheumatic fever is not a genetically inherited condition, but a complication of strep throat caused by a bacterial infection. There is no evidence to suggest that having RF would directly affect the genetic implications for future offspring.
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