The emergency department nurse admits a patient who presents with penetrating abdominal trauma. On exam, the patient is agitated, disoriented, and cannot remember how they got to the hospital. What is the priority action by the nurse?

Stabilize the penetrating object.

Contact the health care provider.

Obtain the client’s vital signs.

Have the unlicensed assistive personnel place wrist restraints.

Answer and Explanation

The Correct Answer is C

A. Stabilize the penetrating object: Stabilizing the object is important to prevent further internal injury and bleeding. However, immediate assessment of the patient’s vital signs takes priority to determine hemodynamic stability and guide emergent interventions. Life-threatening conditions must be identified before procedural measures.

B. Contact the health care provider: Notifying the provider is necessary for treatment planning, but it should occur after the nurse has rapidly assessed the patient’s condition. Vital signs provide critical information to communicate effectively about the patient’s urgency and status.

C. Obtain the client’s vital signs: Assessing vital signs is the priority because the patient’s agitation, disorientation, and altered memory may indicate hypovolemic shock, internal hemorrhage, or head injury. Early detection of hypotension, tachycardia, or hypoxia is essential to initiate lifesaving interventions immediately.

D. Have the unlicensed assistive personnel place wrist restraints: Restraints may be considered only if the patient poses a danger to self or others, and only after safety measures and assessments are completed. Applying restraints prematurely does not address potentially life-threatening physiologic instability.

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Correct Answer is D

Explanation

A. Paradoxic movement of the chest is noted: Paradoxical chest movement is characteristic of a flail chest, where a segment of the rib cage moves in the opposite direction during respiration. While both conditions are life-threatening, flail chest involves structural instability rather than the rapid intrathoracic pressure changes seen in tension pneumothorax.

B. Sucking sound with each patient breath: A sucking sound, or "sucking chest wound," is associated with an open pneumothorax, where air enters the pleural space through a chest wall defect. Unlike tension pneumothorax, this condition does not create progressive mediastinal shift or hemodynamic compromise.

C. Wheezes are audible throughout both lungs: Wheezing indicates airway obstruction or bronchospasm, commonly seen in asthma or COPD exacerbations. It does not reflect the pathophysiology of tension pneumothorax, which primarily involves pleural pressure buildup and compression of mediastinal structures.

D. Tracheal deviation to the unaffected side: Tracheal deviation away from the affected side is a hallmark sign of tension pneumothorax. As air accumulates in the pleural space under pressure, it shifts the mediastinum, compresses the heart and great vessels, and can rapidly lead to decreased cardiac output and life-threatening hypotension. Immediate needle decompression is required.

A. Bradycardia and increased work of breathing. B. Cyanosis and apprehension. C. Dyspnea and tachypnea. D. Respiratory distress and frothy sputum.

Correct Answer is C

Explanation

A. Bradycardia and increased work of breathing: Bradycardia is not typically an early sign of ARDS; it may develop later due to hypoxia or cardiac compromise. Increased work of breathing can occur, but bradycardia is not a reliable early manifestation.

B. Cyanosis and apprehension: Cyanosis and anxiety may appear as ARDS progresses and hypoxemia worsens, but these are usually later signs after respiratory compromise has advanced. Early recognition relies on subtler, more common findings.

C. Dyspnea and tachypnea: Dyspnea (shortness of breath) and tachypnea (rapid breathing) are the most common early manifestations of ARDS. They reflect impaired gas exchange from alveolar-capillary membrane injury and pulmonary edema. Early recognition of these signs allows prompt intervention to prevent progression to severe hypoxemia.

D. Respiratory distress and frothy sputum: Frothy sputum is more characteristic of cardiogenic pulmonary edema rather than ARDS. While respiratory distress is present, frothy sputum is not a typical early finding in ARDS, which initially presents with subtle hypoxemia and increased respiratory effort.

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The emergency department nurse admits a patient who presents with penetrating abdominal trauma. On exam, the patient is agitated, disoriented, and cannot remember how they got to the hospital. What is the priority action by the nurse?

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