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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Free Nursing Study Resources

Correct Answer is C

Explanation

A) A Rhinovirus infection can cause cancer of the cervix
Rhinovirus is primarily associated with the common cold and respiratory infections, not with cervical cancer. The risk factors for cervical cancer are related to persistent infections with certain strains of the human papillomavirus (HPV), especially high-risk types like HPV-16 and HPV-18, which can lead to cervical dysplasia and, eventually, cervical cancer.

B) Eating foods high in fat and taking birth control pills are risk factors
While diet and certain medications may influence overall health, eating foods high in fat and taking birth control pills are not primary risk factors for cervical cancer. Research has shown that certain hormonal contraceptives (especially long-term use) may slightly increase the risk of cervical cancer, but the most significant and well-established risk factor is HPV infection, not fat intake or birth control use.

C) The earlier the age of sexual activity and the more partners, the greater the risk
The major risk factor for cervical cancer is persistent infection with high-risk HPV. Early initiation of sexual activity and having multiple sexual partners increase the risk of HPV infection, which is a leading cause of cervical cancer. HPV is transmitted through sexual contact, and early exposure to the virus, as well as repeated exposure to multiple partners, increases the likelihood of acquiring a high-risk strain of HPV.

D) Having yearly Pap smears will protect you from developing cancer
While Pap smears (Pap tests) are important for detecting precancerous changes (such as dysplasia) or early-stage cervical cancer, they do not prevent cancer. Pap smears can help identify abnormal cell changes that can be treated before they develop into cancer, but they do not protect against the development of cancer.

A. Urine output of 0.5-1 mL/kg/hr B. Serum sodium level 149 mEq/L. (normal 135-145) C. Blood pressure 82/54 D. Heart rate 124 beats per minute

Correct Answer is A

Explanation

A) Urine output of 0.5-1 mL/kg/hr:
This is a positive outcome during fluid resuscitation for burn patients. Adequate urine output is a key indicator of proper renal perfusion and fluid balance. A urine output of 0.5-1 mL/kg/hr is considered optimal for burn patients during the first 24-48 hours of resuscitation. It suggests that the kidneys are receiving sufficient blood flow and that the patient is responding appropriately to the fluids being administered.

B) Serum sodium level 149 mEq/L (normal 135-145):
A serum sodium level of 149 mEq/L is high and indicates hypernatremia, which is a common complication of excessive fluid resuscitation, particularly with the use of crystalloids. Hypernatremia can lead to cerebral edema, altered mental status, and other severe complications. Therefore, this finding would suggest improper fluid management and would not be considered a positive outcome.

C) Blood pressure 82/54:
A blood pressure of 82/54 is hypotensive, which is concerning in a burn patient. Hypotension indicates inadequate tissue perfusion, potentially leading to shock and organ failure. While low blood pressure may occur in the initial stages of resuscitation due to the rapid shifts in fluid, a sustained low blood pressure is not a positive outcome.

D) Heart rate 124 beats per minute:
A heart rate of 124 beats per minute is tachycardic and suggests that the patient is compensating for hypovolemia or inadequate circulatory volume, possibly due to insufficient fluid resuscitation. Although an elevated heart rate may occur as a compensatory mechanism in the initial stages of burn resuscitation, sustained tachycardia indicates ongoing volume depletion or inadequate perfusion and is not an ideal outcome.

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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?

Nursing Test Bank

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Correct Answer is C

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