Which of these findings would be the most significant when assessing a patient who has multiple traumas as a result of a motor vehicle accident?
1. a respiratory rate of 24 breaths per minute
2. a heart rate of 100 beats per minute
3. hypotension
4. pain in one arm
3
Rationale: In a patient who has multiple traumas, traumatic hemorrhage as evidenced by hypotension may not be evident until more than 30 percent of blood volume has been lost. The presence of hypotension indicates severe hemorrhage and requires immediate intervention. A respiratory rate of 24 breaths per minute and a heart rate of 100 beats per minute are not significant and may be caused by anxiety. Pain in one arm may indicate musculoskeletal trauma and is not the most significant in this case.
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1. Orange juice. 2. Black or green tea. 3. Milk. 4. Tomato juice.
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When assessing the skin of a patient with Addison's disease, the nurse would expect which of the following skin manifestations?
A) Bronzed skin appearance B) Presence of plaque C) Peripheral cyanosis D) Vitiligo
A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
a. Administer pain medication every 4 hours as needed. b. Turn the patient every 2 hours, even hours. c. Monitor vital signs, especially rhythm. d. Keep the bed side rails up at all times.