During the assessment the nurse suspects a patient with injuries from a motor vehicle crash sustained kidney trauma. What did the nurse assess to make this clinical decision?
Select all that apply.
1. Turner sign
2. nausea and vomiting
3. microscopic hematuria
4. blood pressure 88/58 mm Hg
5. heart rate 118 beats per minute
Correct Answer: 1, 3, 4, 5
In kidney trauma retroperitoneal bleeding from the kidney may cause Turner sign, a bluish discoloration of the flank. The primary manifestation of kidney trauma includes microscopic hematuria. In kidney trauma signs of shock such as hypotension and tachycardia can occur. Nausea and vomiting are not manifestations of kidney trauma.
You might also like to view...
Signs of wear and tear on the body as the result of aging include all of the following except
a. Replaced knees b. Use of a walker c. Slow gait d. Chronic diseases
Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
a. The spinous process of C7. b. Usually nonpalpable in most individuals. c. Opposite the interior border of the scapula. d. Located next to the manubrium of the sternum.
A student nurse is teaching a patient from an unfamiliar culture about diabetic self-care
The patient is willing and able to take blood glucose readings and give insulin injections but will not use the sliding scale insulin protocol the physician has ordered. Which action by the student would be most beneficial? a. Ask why the patient is unwilling to follow the scale. b. Assess the patient's health-related value system. c. Call the physician and ask for a simplified regimen. d. Have someone else try to teach the sliding scale.
A 75-year-old male client is brought to the clinic by his son. The son states, "Ever since Mom died, Dad hasn't been the same. At first he just seemed sad, but now he seems to get mixed up about everything
" The nurse is aware that based on the client's history, the source of confusion is most likely: a. Dementia b. Depression from the loss of his wife c. Hypoxia of the brain d. Delirium from medications