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.

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Correct Answer is B

Explanation

A) Monitoring the skin color and turgor:
While monitoring skin color and turgor is important in assessing fluid status and perfusion, it is not the immediate priority following an intracoronary stent insertion. Skin turgor is more useful in assessing dehydration or hypovolemia, but after a stent placement, the priority is to ensure the client is stable hemodynamically and there are no complications such as bleeding or thrombosis at the insertion site.

B) Monitoring the blood pressure every fifteen minutes:
Following an intracoronary stent insertion, it is crucial to monitor the client's blood pressure closely, as this procedure can lead to complications such as bleeding, clot formation, or vessel rupture. Monitoring blood pressure frequently (every 15 minutes initially) helps detect any signs of hypotension or hypertension that may indicate complications like bleeding or a clot.

C) Monitoring the cardiac enzymes every eight hours:
Cardiac enzymes, such as troponin, are typically used to assess myocardial injury and can be elevated in the setting of acute coronary syndrome. However, this is not the immediate priority post-procedure. The primary concern immediately after an intracoronary stent insertion is ensuring hemodynamic stability and preventing complications such as bleeding or thromboembolism, rather than focusing solely on enzyme levels.

D) Performing neurological checks every fifteen minutes:
Neurological checks are important in cases of stroke, neurological compromise, or complications like a clot dislodging. However, in the context of a patient who has just had an intracoronary stent placement, neurological checks are not the immediate priority unless there are signs of neurological symptoms (such as sudden weakness or confusion) that indicate a complication like an embolism or stroke.

A. Measure heart chamber pressures to assess for heart failure B. Determine cardiac output during the procedure. C. Evaluate the extent of the occlusion of the coronary arteries involved D. Prevent extensive myocardial damage

Correct Answer is D

Explanation

A) Measure heart chamber pressures to assess for heart failure:
Measuring heart chamber pressures is an important diagnostic tool in assessing heart failure, but it is not the primary goal in the case of a STEMI (ST-Elevation Myocardial Infarction). In STEMI, the primary goal is to identify and treat the blockage in the coronary arteries that is causing the heart attack.

B) Determine cardiac output during the procedure:
Cardiac output is a useful measurement for assessing heart function, but it is not the main focus during the treatment of STEMI. While monitoring cardiac output may be part of the overall care, the urgent priority in STEMI management is to restore blood flow to the affected myocardial tissue as quickly as possible to minimize damage, not to measure cardiac output.

C) Evaluate the extent of the occlusion of the coronary arteries involved:
While evaluating the extent of coronary artery occlusion is part of the process during a cardiac catheterization, the immediate priority for a patient with STEMI is to treat the blockage, not just evaluate it. While the angiogram will reveal the blockage, the treatment goal is to restore perfusion to the affected area of the heart through procedures such as balloon angioplasty or stent placement.

D) Prevent extensive myocardial damage:
This is the correct answer. The main goal of treatment for STEMI is to prevent extensive myocardial damage. In a STEMI, the coronary artery is blocked, depriving the heart muscle of oxygen, which can cause significant damage or death of the myocardial tissue. The most effective way to limit the extent of damage is to restore blood flow as quickly as possible, often through emergent procedures like percutaneous coronary intervention (PCI) or fibrinolytic therapy.

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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?

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The nurse is caring for a client diagnosed with acute coronary syndrome who has just returned to the nursing unit following an intracoronary stent insertion. Which action is the priority at this time?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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