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
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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Related Questions
Correct Answer is A
Explanation
A. "I will keep my baby in an upright position after feedings."
Gastroesophageal reflux (GER) is a condition where the stomach contents flow back into the esophagus, which can cause spitting up or regurgitation in infants. Keeping the baby in an upright position after feedings can help reduce the likelihood of reflux episodes. By holding the baby in an upright position for about 30 minutes after feeding, gravity can aid in keeping the stomach contents from flowing back into the esophagus.
The other statements are incorrect or do not address the management of gastroesophageal reflux:
B. "My baby's formula can be thickened with oatmeal." - Thickening formula with oatmeal is not a standard recommendation for managing GER in infants. In some cases, thickening formulas may be recommended, but it should be done under the guidance of a healthcare provider.
C. "I should position my baby side-lying during sleep." A side-lying position is not recommended for sleep in infants, as it increases the risk of sudden infant death syndrome (SIDS). The safe sleep position for infants is on their back.
D. "I will have to feed my baby formula rather than breast milk." - The type of feeding (formula or breast milk) does not directly impact the occurrence of gastroesophageal reflux. Both breast milk and formula can cause reflux in some infants. It is essential to discuss feeding options with a healthcare provider to determine the best approach for the individual infant's needs.
Correct Answer is C
Explanation
A. Gastrointestinal:
Kawasaki disease primarily affects blood vessels, and the gastrointestinal system is not the main target of this condition. While gastrointestinal symptoms can occur as part of the overall inflammatory response, such as abdominal pain, vomiting, or diarrhea, they are not the primary focus of concern in Kawasaki disease. The most critical system to monitor in Kawasaki disease is the cardiovascular system, specifically the coronary arteries.
B. Respiratory:
The respiratory system is not the primary system affected by Kawasaki disease. While respiratory symptoms can occur as part of the overall inflammatory response and fever associated with the disease, such as coughing or runny nose, they are not the main concern in Kawasaki disease. The primary system to monitor in this condition is the cardiovascular system, especially the coronary arteries.
C. Cardiovascular:
This is the correct answer. Kawasaki disease is primarily a vasculitis (inflammation of blood vessels) that affects various blood vessels, including the coronary arteries. The inflammation of the coronary arteries can lead to coronary artery aneurysms and other cardiac complications. Monitoring the cardiovascular system is essential to detect any signs of coronary artery involvement and ensure timely intervention to prevent potential long-term cardiac problems.
D. Integumentary:
The integumentary system (skin) is not the primary focus of Kawasaki disease. While some skin changes can occur during the acute phase of the disease, such as a rash or peeling skin on the hands and feet, these are not the primary concerns. Monitoring the cardiovascular system is critical in Kawasaki disease due to the risk of coronary artery inflammation and potential complications.
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