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 C
Explanation
Consuming a large amount of milk, such as a quart a day, can lead to iron deficiency anemia in toddlers. Milk is a poor source of iron, and excessive milk intake can displace other iron-rich foods from the toddler's diet.
Iron deficiency anemia occurs when the body lacks sufficient iron to produce enough hemoglobin, which is essential for oxygen transport in the blood. Toddlers are particularly vulnerable to iron deficiency anemia because they have increased iron needs for growth and development.
Option A (Obesity) and option B (Diabetes mellitus) are not directly related to the toddler's milk consumption. Obesity may be a concern if the child consumes excessive calories overall, but it is not specifically associated with milk intake. Similarly, diabetes mellitus is not directly related to milk consumption.
Option D (Rickets) is caused by a deficiency of vitamin D, not iron. Rickets results in weakened and deformed bones, and it is usually associated with inadequate sunlight exposure and insufficient dietary vitamin D. While milk is often fortified with vitamin D, excessive milk intake can displace other vitamin D sources in the diet and contribute to an increased risk of rickets, but the primary concern with excessive milk intake is iron deficiency anemia.
Correct Answer is ["5.3."]
Explanation
To calculate the dose of acetaminophen for a child, the nurse needs to convert the child's weight from pounds to kilograms and then multiply it by the prescribed dose per kilogram. The formula is:
Weight in kg = Weight in lb / 2.2
Dose in mg = Weight in kg x Dose per kg
Dose in mL = Dose in mg / Concentration in mg/mL
Using the given information, the nurse can plug in the values and solve for the dose in mL:
Weight in kg = 28 / 2.2 = 12.73
Dose in mg = 12.73 x 10 = 127.3
Dose in mL = 127.3 / 120 x 5 = 5.3
Therefore, the nurse should administer 5.3 mL of acetaminophen to the child.
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