When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

increase in temperature.

decrease in pulse.

decrease in blood pressure.

decrease in respirations.

Answer and Explanation

The Correct Answer is C

A.   Temperature often decreases in cases of severe blood loss due to shock and hypothermia.
B.   A decrease in pulse is unlikely in severe blood loss. The body compensates with an increased heart rate.
C.   A decrease in blood pressure is expected in cases of significant blood loss, as the body struggles to maintain adequate circulation.
D.   Respirations may increase in response to blood loss, not decrease, as the body attempts to increase oxygen intake.

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Correct Answer is C

Explanation

A. While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B. The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C. Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D. Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.

A. "You stand 20 feet away from the chart while I test each of your eyes." B. The number beside the largest print read is your visual acuity score! C. "I will be testing your vision with your reading glasses on." D. "You stand 50 feet away from the chart while I test each of your eyes."

Correct Answer is A

Explanation

A. The patient should stand 20 feet away from the Snellen chart to accurately measure visual acuity, which is the standard procedure.

B. The number beside the largest print is not the correct visual acuity score; the patient must read progressively smaller lines.
C. Testing with reading glasses is appropriate only for patients who need them for close-up vision, but the Snellen test typically measures distance vision.
D. The distance should be 20 feet, not 50 feet, to ensure proper testing conditions.

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When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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