A woman has come to the emergency department with multiple ...

[Zulu123]

A woman has come to the emergency department with multiple bruises over her body and a small laceration over her upper lip. She says she fell down the stairs while doing her housework.
 
  Which observation would most likely cause the nurse to suspect that she has been a victim of battering? 1. The client is hesitant to provide details about how the injuries occurred.
  2. The client was accompanied to the emergency department by her mother instead of her partner.
  3. The client has sought care quickly after the incident.
  4. The client does not seem to be in pain.

Question 2

The prenatal clinic nurse is caring for a patient with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first?
 
  1. Weigh the client.
  2. Give 1 liter of lactated Ringer's solution IV.
  3. Administer 30 ml Maalox (magnesium hydroxide) orally.
  4. Encourage clear liquids orally.

[ryhom]

Answer to Question 1

1
Explanation: 1. Hesitation to provide detailed information about the injury and how it occurred is a common sign of abuse.

Answer to Question 2

2
Rationale 1: Weighing the client provides information on weight gain or loss, but is not the top priority in a patient with excessive vomiting during pregnancy. The vital signs indicate hypovolemia.
Rationale 2: The vital signs indicate hypovolemia. Giving this patient a liter of lactated Ringer's solution intravenously will re-establish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.
Rationale 3: The vital signs indicate hypovolemia. There is no indication that the patient has dyspepsia.
Rationale 4: Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia.

[Zulu123]

Excellent

[bdobbins]

TYSM