A child diagnosed with hemophilia presents to the emergency department (ED) with multiple injuries following a motor vehicle crash. Which injury is the priority when conducting the nursing assessment?
1. Occipital hematoma
2. Radial fracture
3. Dislocated shoulder
4. Abdominal abrasions
1
Explanation:
1. A potential intracranial bleed would receive highest priority because of the danger of increased intracranial pressure and potential neurologic damage.
2. Although at risk for bleeding, this would not take priority over a head injury.
3. A dislocation is not at high risk for bleeding or tissue ischemia.
4. Although at risk for bleeding, this would not take priority over a head injury.
You might also like to view...
A middle-aged female patient has been admitted to the outpatient treatment unit of the hospital for an edrophonium (Tensilon) test
Shortly after the administration of the medication, the patient reports that her muscle strength is significantly weaker than before the test. The nurse who is participating in the test should recognize that this finding is suggestive of what diagnosis? A) Alzheimer's disease B) Anticholinergic crisis C) Myasthenia gravis D) Cholinergic crisis
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform?
A) Administer the platelets as rapidly as the patient can tolerate. B) Establish IV access as soon as the platelets arrive from the blood bank. C) Ensure that the patient has a patent central venous catheter. D) Aspirate 10 to 15 mL of blood from the patient's IV immediately following the transfusion.
An outpatient has been self-monitoring blood pressure readings since beginning reserpine (Serpasil) for hypertension 3 days ago. The patient reports, "My blood pressure has not changed since I started taking the medication"
Which of the following should the nurse advise the patient to do? a. "Take an extra dose now and recheck your blood pressure tomorrow." b. "Discontinue the medication and come to the office immediately." c. "This is normal. The effects may not be evident for a full week." d. "Another medication is needed with the treatment regimen."
The mortality rate for burns is highest in the very young and in the elderly population. What factors put the very young at a higher risk? Select all that apply
1. Infants and young children have an immature immune system with a weak antibody response. 2. The very young have a greater proportion of body surface area per amount of body mass, resulting in a higher risk for fluid-volume loss. 3. The very young have an increased risk for the development of hypovolemic shock. 4. In the very young, burns tend to exacerbate previous medical problems. 5. The very young tend to heal more slowly.