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 A
Explanation
A. Apex of the heart:The apex of the heart is the preferred site for measuring an infant's heart rate. It is located at the 4th or 5th intercostal space, just medial to the midclavicular line, allowing for accurate auscultation of the heartbeat.
B. Carotid artery:While the carotid artery can be used to assess heart rate in older children and adults, it is not ideal for infants due to the risk of compromising circulation to the brain if pressure is applied too forcefully.
C. Brachial artery:The brachial artery is often used to assess pulse in infants, especially in cases of CPR, but it is not the preferred site for routine heart rate measurement. It may be used when assessing circulation or checking for pulses, but auscultation at the apex is more accurate for heart rate.
D. Radial artery:The radial artery can be difficult to palpate in infants due to their small size and is generally not used for heart rate assessment in this age group. The apex is a more reliable location.
Correct Answer is B
Explanation
When providing teaching to a parent of a child with celiac disease, the nurse should recommend food choices that are gluten-free. Celiac disease is an autoimmune disorder triggered by the ingestion of gluten, which is a protein found in wheat, barley, rye, and their derivatives. Gluten damages the small intestine lining in individuals with celiac disease, leading to various gastrointestinal and nutritional issues.
The correct food choice for a child with celiac disease is B. Rice. Rice is naturally gluten-free and can be a safe and nutritious option for individuals with celiac disease. Other gluten-free options include corn, quinoa, oats (certified gluten-free oats), potatoes, and many fruits and vegetables.
A. Barley: Barley contains gluten, which is harmful to individuals with celiac disease. It should be avoided in the child's diet.
C. Rye: Rye also contains gluten and should be avoided in the child's diet. It can cause damage to the small intestine in individuals with celiac disease.
D. Wheat: Wheat is a primary source of gluten and is strictly off-limits for individuals with celiac disease. It is essential to avoid all wheat-containing products, including bread, pasta, and baked goods.
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