A nurse in the emergency department is assessing a patient who has a suspected flail chest.
Which of the following findings does the nurse recognize as common with flail chest?

Paradoxical chest movement is the hallmark sign of flail chest. This occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. During inspiration, the negative intrathoracic pressure causes the unstable segment to be pulled inward, while the rest of the chest expands. During expiration, the segment bulges outward, opposite the normal movement of the chest wall.

Choice B rationale

Flail chest involves significant trauma to the chest wall, including multiple rib fractures. This causes severe pleuritic pain, which is exacerbated by the movement of the chest wall during inspiration. The fractured ribs and associated soft tissue injury irritate the parietal pleura, leading to a sharp, stabbing pain that the patient describes as being worse with deep breaths.

Choice C rationale

Bradycardia is not a typical finding in flail chest. The patient's pain, respiratory distress, and potential hypoxemia trigger a sympathetic nervous system response. This compensatory mechanism leads to an increase in heart rate to maintain cardiac output and oxygen delivery to the tissues. Therefore, tachycardia is a more expected finding in a patient with flail chest. Normal heart rate is 60 to 100 beats per minute.

Choice D rationale

Jaundice, characterized by yellowing of the skin and eyes, is a result of hyperbilirubinemia, a condition associated with liver dysfunction, biliary obstruction, or excessive red blood cell destruction. It is not a direct finding or complication of flail chest, which is a musculoskeletal and respiratory injury. Jaundice would be a coincidental finding and not a direct sign.

Choice E rationale

Chest pain is a prominent and expected finding in a patient with flail chest. The pain is a direct result of the trauma, including multiple rib fractures and the associated soft tissue and muscle injury. The severity of the pain is often directly related to the number and location of the fractures and is a major contributor to the patient's respiratory distress. .

Choice A rationale

A patient with a new spinal cord injury on a rotating bed is not at a high risk for developing a pulmonary embolism. The rotating bed is specifically designed to prevent complications associated with immobility, such as venous stasis and pressure ulcers. The constant movement of the bed helps to maintain blood flow and prevent the pooling of blood in the extremities, thereby reducing the risk of deep vein thrombosis and subsequent pulmonary embolism.

Choice B rationale

A young obese patient with a fractured femur is at a high risk for developing a pulmonary embolism. Obesity is a hypercoagulable state, increasing the baseline risk of thrombus formation. A fractured femur, especially if it requires immobilization, causes significant venous stasis and potential endothelial injury. This combination of factors, adhering to Virchow's triad, creates a highly prothrombotic environment, making the development of DVT and PE very likely.

Choice C rationale

A patient who had a reaction to contrast dye yesterday is not at a high risk for developing a pulmonary embolism. Allergic reactions to contrast dye are typically associated with hypersensitivity responses, affecting systems such as the respiratory, cardiovascular, and integumentary. There is no known physiological mechanism or evidence to suggest that a contrast dye reaction, even a severe one, directly increases the risk of developing a pulmonary embolism in the subsequent days.

Choice D rationale

An older patient who is one day post hip replacement surgery is at a very high risk for developing a pulmonary embolism. Surgical procedures, particularly orthopedic surgeries like hip replacements, cause significant endothelial injury and a hypercoagulable state. The post-operative period often involves extended immobility, leading to venous stasis. These three components of Virchow's triad converge to create an ideal environment for the formation of a deep vein thrombosis, which can easily embolize to the lungs.

Choice E rationale

A young man with an exacerbation of asthma is not at a high risk for developing a pulmonary embolism. Asthma is a chronic inflammatory disease of the airways characterized by bronchoconstriction. While a severe asthma exacerbation can lead to hypoxemia and respiratory distress, it does not directly cause the hypercoagulable state, venous stasis, or endothelial injury necessary to form a deep vein thrombosis. Therefore, it is not a direct risk factor for a pulmonary embolism