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Asked by BrigadierWallaby1911

The nurse is caring for a 24-year-old male client in the trauma unit. The client was brought into the emergency department by a friend after sustaining 2 gunshot wounds, one on the abdomen and one on his right foot.

 

Nurses’ Notes

1215: The client is oriented to person, place, and time. He is extremely lethargic and feeling and nauseous. Pupils are equal, round, reactive to light and accommodating. GCS is 14. Pain rated as 10/10 in the abdomen with guarding. Respirations are labored and tachypneic. Lung sounds are clear bilaterally with vesicular breath sounds heard over lung fields. 1+ radial pulses, weak and thready. Abdomen is firm, tender, and distended. No bowel sounds heard. Extensive bleeding is observed from the ULQ of the abdomen near the umbilicus, no exit wound is identified. Exit wound identified on right foot. No pulses present on the right foot. No signs of pitting edema. He is relatively healthy male with no significant medical history and takes no medications.

 

Vital Signs:

P: 124

RR: 29

BP: 89/61

T: 37.5 C (99.5 F)

O2: 92% on Room air

 

The nurse has reviewed the client’s Vital Signs.

Which of the following conditions is the client at the highest risk for?

 

Select one:

1. Sepsis

2. Epidural hematoma

3. Compartment Syndrome

4. Seizure

SCIENCE
HEALTH SCIENCE
NURSING
NUR 134

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