A patient is admitted with injuries sustained from a skiing accident
While completing the primary survey, the nurse suspects the patient has an injury to the spleen because of which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Heart rate 120
2. Referred pain to the left shoulder
3. Upper left quadrant abdominal pain
4. Hematuria
5. Flank ecchymosis
1,2,3
Rationale 1: A rapid heart rate can indicate hemorrhage or hypovolemic shock which is an assessment finding consistent with an injury to the spleen.
Rationale 2: Kehr's sign is referred pain to the left shoulder. This is an assessment finding consistent with an injury to the spleen.
Rationale 3: Upper left quadrant abdominal tenderness or pain is an assessment finding consistent with an injury to the spleen.
Rationale 4: Hematuria is not an assessment finding consistent with an injury to the spleen.
Rationale 5: Bruising or ecchymosis over the flank area is not an assessment finding consistent with an injury to the spleen.
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