A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

Muffled heart tones.

Bilateral sonorous wheezes.

Widening pulse pressure.

Decreased urinary output.

Answer and Explanation

The Correct Answer is A

A. Muffled heart tones. Muffled heart tones in a client with blunt chest trauma are a key sign of cardiac tamponade, a life-threatening emergency where blood or fluid accumulates in the pericardial sac, preventing proper cardiac filling. This condition is part of Beck's triad (muffled heart tones, hypotension, and jugular vein distention) and requires immediate intervention, such as pericardiocentesis, to relieve pressure on the heart.
B. Bilateral sonorous wheezes. While wheezing indicates airway obstruction or bronchospasm, it is not as immediately life-threatening as cardiac tamponade. The nurse should continue monitoring and consider interventions like bronchodilators, but the priority is addressing muffled heart tones.
C. Widening pulse pressure. A widening pulse pressure (increased difference between systolic and diastolic BP) is typically associated with increased intracranial pressure (ICP) rather than blunt chest trauma. In chest trauma, a narrowing pulse pressure (e.g., in hypovolemic or obstructive shock) would be a greater concern.
D. Decreased urinary output. Reduced urine output may indicate shock or poor perfusion, but it is not the most urgent finding compared to muffled heart tones, which suggest impending cardiovascular collapse. While decreased urinary output should be addressed, cardiac tamponade takes priority due to the immediate risk of death.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Provide a bedside table for the client to lean across. Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
B. Place bed in the reverse Trendelenburg position. Reverse Trendelenburg elevates the head and lowers the feet, which does not specifically relieve pain associated with pancreatitis. The client instinctively leans forward for relief, and adjusting the bed position would not provide the same benefit. This intervention does not directly address the underlying cause of discomfort.
C. Encourage bed rest until analgesic takes effect. Although pain control is essential, keeping the client in a supine or bedrest position can increase abdominal pressure and worsen discomfort. Allowing the client to assume a comfortable position enhances the effectiveness of analgesics and prevents unnecessary distress. Pain relief strategies should focus on both pharmacologic and positioning interventions.
D. Raise the head of the bed to a 90-degree angle. Elevating the head of the bed can improve breathing and reduce reflux, but it does not provide the same pressure relief as leaning forward. Sitting upright without forward support does not effectively relieve peritoneal irritation from pancreatic inflammation. Providing a bedside table supports proper positioning and enhances comfort.

A. Measure the client's abdominal girth. B. Monitor the client's recent hemoglobin levels. C. Prepare for nasogastric tube (NGT) insertion. D. Notify the healthcare provider (HCP) of the client's status.

Correct Answer is D

Explanation

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

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A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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