The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
Cardiac tamponade
Pneumothorax
Aspiration
Splenic laceration
The Correct Answer is B
A. Cardiac tamponade: Cardiac tamponade typically presents with hypotension, jugular venous distension, and muffled heart sounds (Beck’s triad). While shortness of breath may occur, the use of accessory muscles is not a defining feature. Chest pain is usually retrosternal and not always associated with respiratory distress.
B. Pneumothorax: Pneumothorax presents with chest pain, dyspnea, and increased use of accessory muscles due to impaired lung expansion. These signs indicate compromised ventilation and decreased oxygenation. Trauma is a common cause, making this a likely condition. Rapid assessment and intervention are essential.
C. Aspiration: Aspiration can cause sudden coughing, choking, and possible hypoxia, but it is not typically associated with chest trauma or immediate accessory muscle use. It is less likely in the context of a motor vehicle accident.
D. Splenic laceration: Splenic injury usually presents with left upper quadrant abdominal pain, referred shoulder pain, and signs of internal bleeding such as hypotension and tachycardia. Respiratory distress and accessory muscle use are not typical features.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Narrowing pulse pressure, bradycardia, irregular heart rate: Narrowing pulse pressure is not characteristic of increasing ICP. ICP elevation typically causes widening pulse pressure, making this combination inconsistent with the classic signs of herniation.
B. Stiff neck, bradycardia, narrowing pulse pressure: While a stiff neck may indicate meningeal irritation, it is not a primary sign of rising ICP. Narrowing pulse pressure does not align with the hemodynamic changes seen in Cushing’s triad.
C. Bradycardia, irregular breathing, widening pulse pressure: The Cushing’s triad is the hallmark of increased ICP. It reflects the body’s response to maintain cerebral perfusion: systolic hypertension widening pulse pressure, bradycardia from baroreceptor reflex, and irregular respirations from brainstem compression.
D. Narrow pulse pressure, bradycardia, irregular respirations: Narrow pulse pressure is inconsistent with elevated ICP, which usually produces hypertension with a widened pulse pressure. The other signs may occur, but the combination does not match the classic presentation of ICP elevation.
Correct Answer is D
Explanation
Calculation:
- Calculate the Total 24-Hour Fluid Volume
The Parkland formula is: Total Volume = 4 mL × Weight (kg) × % TBSA burned
Weight: 72 kg
% TBSA Burned: 60%
Total Volume = 4 × 72 × 60
= 17,280 mL
- Calculate the Volume to be Infused in the First 8 Hours
Half of the total 24-hour volume is given in the first 8 hours.
Volume for 8 hours = Total Volume ÷ 2
= 17,280 ÷ 2
= 8,640 mL
- Calculate the Infusion Rate for the First 8 Hours
Flow Rate = Volume for 8 hours ÷ 8 hours
= 8,640 ÷ 8
= 1,080 mL/hr
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