In providing care to a patient who sustained left sided 10th through 12th rib fractures, the nurse notes Kehr's Cullen's and Gray Turner's signs during assessment. Which abdominal organ is most likely to be affected by this trauma?
Intestines
Liver
Spleen
Stomach
The Correct Answer is C
A) Intestines:
While abdominal trauma can affect the intestines, Kehr's sign, Cullen's sign, and Gray Turner's sign are more commonly associated with damage to the spleen rather than the intestines. Kehr's sign, in particular, is a hallmark of splenic injury, with pain referred to the left shoulder due to diaphragmatic irritation from blood in the peritoneum.
B) Liver:
Liver injuries often present with right upper quadrant pain, jaundice, and elevated liver enzymes. While liver injuries can cause internal bleeding, Cullen's and Gray Turner's signs are more closely associated with retroperitoneal bleeding from the spleen rather than liver injuries. Kehr's sign, which is left-sided shoulder pain, would not typically indicate a liver injury.
C) Spleen:
The spleen is the most likely abdominal organ affected in this case due to the left-sided rib fractures. When the spleen is injured (often as a result of blunt trauma), it can cause intraperitoneal hemorrhage. This bleeding can irritate the diaphragm, leading to Kehr's sign, which presents as left shoulder pain. Additionally, Cullen's sign (periumbilical bruising) and Gray Turner's sign (flank bruising) are indicative of retroperitoneal bleeding, which can occur with splenic rupture or laceration.
D) Stomach:
While stomach injuries can occur with blunt abdominal trauma, they are less likely to cause the signs and symptoms seen in this patient (Kehr's, Cullen's, and Gray Turner's signs). Stomach trauma typically leads to pain and potential perforation, but it doesn't often cause the peritoneal bleeding patterns seen with splenic injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["90"]
Explanation
Given:
Ordered dose of Alteplase: 0.9 mg/kg
Client weight: 220 pounds
Step 1: Convert the client's weight from pounds to kilograms:
1 pound (lb) = 0.453592 kilograms (kg)
Client weight in kg = 220 lbs x 0.453592 kg/lb = 99.76824 kg
Step 2: Calculate the total dose of Alteplase:
Total dose (mg) = Ordered dose (mg/kg) xClient weight (kg)
Total dose (mg) = 0.9 mg/kg x 99.76824 kg
Total dose (mg) = 89.801416 mg
Step 3: Round to the nearest whole number:
Total dose (mg) ≈ 90 mg
Correct Answer is ["12"]
Explanation
Given:
Ordered dose of Heparin: 20 units/kg
Patient weight: 132 lbs
Concentration of Heparin: 25,000 units/250 mL (100 units/mL)
Step 1: Convert patient weight from pounds to kilograms:
1 pound (lb) = 0.453592 kilograms (kg)
Patient weight in kg = 132 lbs x 0.453592 kg/lb = 59.87424 kg
Step 2: Calculate the total dose of Heparin:
Total dose (units) = Ordered dose (units/kg) x Patient weight (kg)
Total dose (units) = 20 units/kg x 59.87424 kg
Total dose (units) = 1197.4848 units
Step 3: Calculate the volume to be administered:
Volume (mL) = Total dose (units) / Concentration (units/mL)
Volume (mL) = 1197.4848 units / 100 units/mL
Volume (mL) = 11.974848 mL
Step 4: Round to the nearest whole number:
Volume (mL) ≈ 12 mL
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