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 B
Explanation
A patent ductus arteriosus (PDA) is a congenital heart defect associated with increased pulmonary blood flow. In normal fetal circulation, the ductus arteriosus allows blood to bypass the lungs since the baby receives oxygen from the mother's placenta. After birth, the ductus arteriosus should close, redirecting blood flow to the lungs for oxygenation. However, in some infants with PDA, the ductus arteriosus remains open, causing an abnormal connection between the aorta and the pulmonary artery. As a result, oxygenated blood from the aorta flows back into the pulmonary artery, increasing the workload on the lungs.
The other options are as follows:
A. Coarctation of the aorta - Coarctation of the aorta is a narrowing of the aorta, which obstructs blood flow and leads to increased blood pressure in the upper body and reduced blood flow to the lower body.
C. Tetralogy of Fallot - Tetralogy of Fallot is a combination of four heart defects that results in decreased pulmonary blood flow due to a ventricular septal defect (VSD), overriding aorta, pulmonary stenosis, and right ventricular hypertrophy.
D. Tricuspid atresia - Tricuspid atresia is a congenital heart defect where the tricuspid valve does not develop correctly, resulting in an absent or abnormal tricuspid valve. This defect prevents blood flow from the right atrium to the right ventricle and, therefore, reduces pulmonary blood flow.
Correct Answer is ["1250"]
Explanation
To calculate the daily fluid requirements for a child, you typically use the Holliday-Segar method, which provides guidelines based on the child's weight:
- For the first 10 kg of body weight, you give 100 ml per kg.
- For the second 10 kg of body weight, you give 50 ml per kg.
- For any weight above 20 kg, you give 20 ml per kg.
First, convert the child's weight from pounds to kilograms. To do this, divide the weight in pounds by 2.2.
For a child weighing 33 pounds:
- The weight in kilograms is approximately 15 kg (33 divided by 2.2).
Now, calculate the fluid requirement:
- For the first 10 kg of the child's weight, you need 1000 ml (10 kg multiplied by 100 ml).
- For the remaining 5 kg, you need 250 ml (5 kg multiplied by 50 ml).
Adding these together, the total daily fluid requirement is 1250 ml.
So, the daily fluid requirement for a child weighing 33 pounds is 1250 ml.
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