In providing care to a patient who sustained left sided 10th through 12th rib fractures, the nurse notes Kehr's Cullen's and Gray Turner's signs during assessment. Which abdominal organ is most likely to be affected by this trauma?

Intestines

Liver

Spleen

Stomach

Answer and Explanation

The Correct Answer is C

A) Intestines:
While abdominal trauma can affect the intestines, Kehr's sign, Cullen's sign, and Gray Turner's sign are more commonly associated with damage to the spleen rather than the intestines. Kehr's sign, in particular, is a hallmark of splenic injury, with pain referred to the left shoulder due to diaphragmatic irritation from blood in the peritoneum.

B) Liver:
Liver injuries often present with right upper quadrant pain, jaundice, and elevated liver enzymes. While liver injuries can cause internal bleeding, Cullen's and Gray Turner's signs are more closely associated with retroperitoneal bleeding from the spleen rather than liver injuries. Kehr's sign, which is left-sided shoulder pain, would not typically indicate a liver injury.

C) Spleen:
The spleen is the most likely abdominal organ affected in this case due to the left-sided rib fractures. When the spleen is injured (often as a result of blunt trauma), it can cause intraperitoneal hemorrhage. This bleeding can irritate the diaphragm, leading to Kehr's sign, which presents as left shoulder pain. Additionally, Cullen's sign (periumbilical bruising) and Gray Turner's sign (flank bruising) are indicative of retroperitoneal bleeding, which can occur with splenic rupture or laceration.

D) Stomach:
While stomach injuries can occur with blunt abdominal trauma, they are less likely to cause the signs and symptoms seen in this patient (Kehr's, Cullen's, and Gray Turner's signs). Stomach trauma typically leads to pain and potential perforation, but it doesn't often cause the peritoneal bleeding patterns seen with splenic injuries.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Hypoglycemic event often develops:
Phenytoin is an anticonvulsant, and while it can affect glucose metabolism, hypoglycemia is not a typical consequence of abruptly stopping the drug. This is not a primary concern when discontinuing phenytoin therapy. Hypoglycemia is more commonly associated with medications like insulin or sulfonylureas, not anticonvulsants like phenytoin.

B) Physical dependency on the drug develops over time:
Phenytoin does not cause physical dependence in the way that some other substances (e.g., alcohol, opioids) can. While the body can become used to a medication over time, and withdrawal symptoms can occur, the risk of physical dependence is not the main reason why phenytoin should not be stopped suddenly.

C) A heart block is likely to develop:
Phenytoin is known to have effects on cardiac conduction, and it can cause heart rhythm disturbances like bradycardia or a prolonged PR interval, especially with toxicity. However, the risk of a heart block developing due to abrupt discontinuation of phenytoin is not the primary concern.

D) Status epilepticus may develop:
The most serious risk of suddenly stopping phenytoin, or any anticonvulsant, is the potential for status epilepticus. Status epilepticus is a medical emergency where seizures occur continuously without recovery in between, which can be life-threatening. Abruptly discontinuing phenytoin can lead to a rebound increase in seizure activity, which can result in status epilepticus.

A. insert an oral airway and suction as needed. B. withhold oral fluids and food. C. apply artificial pears to protect the cornea. D. speak clearly while facing the patient.

Correct Answer is B

Explanation

A) Insert an oral airway and suction as needed:
This is generally not the first intervention for impaired glossopharyngeal (CN IX) and vagus nerve (CN X) function. The glossopharyngeal and vagus nerves play a critical role in swallowing, gag reflex, and the ability to protect the airway. While an airway might be necessary in cases of severe dysfunction, withholding food and fluids is a more immediate and specific concern when these cranial nerves are impaired, as it prevents aspiration risk.

B) Withhold oral fluids and food:
The glossopharyngeal nerve (CN IX) is involved in taste and swallowing, and the vagus nerve (CN X) is crucial for the motor control of the pharynx and larynx, which are involved in swallowing and protecting the airway. Dysfunction of these nerves can lead to difficulty swallowing (dysphagia), increased risk for aspiration, and the inability to protect the airway effectively. Withholding oral fluids and food helps prevent aspiration, a major risk when these nerves are impaired, until further assessment and management can be done.

C) Apply artificial tears to protect the cornea:
While it is important to protect the cornea in patients with cranial nerve dysfunction (specifically the facial nerve, CN VII), this does not directly relate to the glossopharyngeal (CN IX) and vagus (CN X) nerves. The glossopharyngeal and vagus nerves affect swallowing and airway protection, not eye lubrication. Applying artificial tears would not address the risk associated with impaired swallowing or airway protection.

D) Speak clearly while facing the patient:
Although speaking clearly and facing the patient might be helpful for communication, especially if the patient has difficulty with speech due to nerve impairment, it does not address the immediate and more critical concern of impaired swallowing and airway protection associated with dysfunction of the glossopharyngeal and vagus nerves. The primary concern is ensuring the patient is not at risk for aspiration while eating or drinking.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

In providing care to a patient who sustained left sided 10th through 12th rib fractures, the nurse notes Kehr's Cullen's and Gray Turner's signs during assessment. Which abdominal organ is most likely to be affected by this trauma?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client newly diagnosed with a seizure disorder about phenytoin sodium therapy. What information should the nurse stress regarding the client stopping the drug suddenly? The drug should not be stopped abruptly because:

Correct Answer is D

Explanation

The neurologic assessment of a patient indicated impaired function of the glossopharyngeal nerve (CN 10) and the vagus nerve (C.N X). Based on these findings, the nurse plans to;

Correct Answer is B

Explanation

The nurse is caring for a patient who sustained a spinal cord injury (SCI) at T1. The alarm on the monitor sounds because the patient's blood pressure is 86/50 and the heart rate is 44. The nurse's priority action would be to:

A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

In providing care to a patient who sustained left sided 10th through 12th rib fractures, the nurse notes Kehr's Cullen's and Gray Turner's signs during assessment. Which abdominal organ is most likely to be affected by this trauma?

A client in the gynecology clinic asks the nurse, ‘’What are the risk factors for developing cervical cancer?’’ Which statement by the nurse is the best response?

A nurse is assisting the provider to care for trauma patient who has been diagnosed with a hemothorax. Which of the following actions should the nurse perform first to treat this cause of obstructive shock?

After sustaining a serious brain injury, the patient has recovered enough to be transferred to a rehabilitation unit for continued care. Which statement by the patient indicates that they understand realistic goal setting?

The nurse is caring for patient with a history of atrial fibrillation who is prescribed warfarin. Sometimes I forget my medication, so l double up doses when I remember " The patient's PT and INR are highly elevated. The nurse anticipates the transfusion of which blood product?