The nurse is concerned that a patient with injuries from a motor vehicle crash is experiencing bleeding from liver trauma. What did the nurse assess to make this clinical determination?
Select all that apply.
1. new onset of pruritus
2. new onset of lightheadedness
3. heart rate 112 beats per minute
4. requesting more water to drink
5. respiratory rate 26 breaths per minute
Correct Answer: 2, 3, 4, 5
Bleeding due to liver trauma may not be immediately apparent. The nurse should suspect bleeding in the presence of light-headedness, rapid heart rate, shortness of breath, or thirst. Pruritus is not a manifestation of bleeding.
You might also like to view...
While discussing gas exchange, the instructor would tell the students that oxygen and carbon dioxide enter and leave the body by what method?
A) Osmosis B) Diffusion C) Passive transport D) Active transport
A study framework reflects the:
a. blueprint for the study. b. data analysis strategy. c. researcher's "theory" or idea about the study. d. specific plan for data collection.
The perinatal nurse explains the cardiopulmonary adaptations that occur in the neonate to a student nurse. Which one of the following statements accurately describes the sequence of these changes?
A) As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance. B) As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life C) Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation D) Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.
In reference to quality control of health care organizations, quality is defined as
a. performing procedures correctly b. meeting the requirements of accrediting agencies c. meeting or exceeding requirements of the customer d. maintaining a good safety record