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

Answer and Explanation

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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Correct Answer is A

No explanation

A. "Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes." B. "Apply ice at the base of the nose for 5 min and then check for bleeding. C. "Place your child in a supine position with a pillow under her back." D. "Place your child in a sitting position with her head tilted back

Correct Answer is A

Explanation

For a child with von Willebrand disease experiencing a nosebleed, the nurse should instruct the parent to have the child sit with their head tilted forward slightly (not backward) to prevent blood from flowing down the throat. Applying direct pressure to the nostrils with fingers or using a clean cloth for about 10 minutes will help stop the bleeding.
Option B (applying ice at the base of the nose) is not recommended because ice can cause vasoconstriction, potentially prolonging bleeding in individuals with bleeding disorders.
Option C (placing the child in a supine position with a pillow under the back) is also not recommended, as this can lead to blood flowing down the throat, increasing the risk of aspiration.
Option D (placing the child in a sitting position with her head tilted back) should be avoided as it can lead to blood flowing into the throat and potentially being swallowed or aspirated. This position is generally discouraged for nosebleeds.

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A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Nursing Test Bank

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