A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen
Which of these statements is true regarding assessment of the spleen in this situation?
a.
The spleen can be enlarged as a result of trauma.
b.
The spleen is normally felt on routine palpation.
c.
If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size.
d.
An enlarged spleen should not be palpated because it can easily rupture.
ANS: D
If an enlarged spleen is felt, then the nurse should refer the person and should not continue to palpate it. An enlarged spleen is friable and can easily rupture with overpalpation.
You might also like to view...
While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?
A) Ineffective health maintenance B) Impaired physical mobility C) Disturbed sensory perception: Kinesthetic D) Ineffective role performance
A patient has been prescribed penicillin G for pharyngitis. She is upset that she has to take the antibiotic around the clock. The nurse will base a response to the patient on the fact that penicillin G
A) has an average peak drug effect of 4 hours. B) needs to bind to plasma protein. C) is rapidly cleared unchanged from the plasma by the kidneys. D) does not penetrate the blood–brain barrier.
The older adult patient in a long-term care facility is at risk for injury because of confusion. The patient's gait is stable. To prevent injury to the patient, the best method of restraint if prescribed would be:
1. a geriatric chair. 2. an alarm bracelet. 3. a vest restraint. 4. wrist and ankle restraints.
The parents of a child with anemia follow a vegetarian eating plan. Which suggestion should the nurse make to the parents to increase the child's iron intake? (Select all that apply.)
a. "Dried fruits are a good source of iron." b. "You can eat beans because they are a good source of iron." c. "Ingest dairy products with the meal to increase absorption." d. "Drinking citrus juice with an iron-rich meal will help with iron absorption." e. "Unfortunately, the only good way to increase iron intake is to provide meat for your child."