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Zorluk: ZorReduction of Risk Potential

An adult client is admitted to the surgical step-down unit following a motor vehicle collision involving blunt abdominal trauma. During the initial shift assessment, the nurse notes the client has become increasingly restless and diaphoretic, and is reporting new-onset pain in the left shoulder. The client's vital signs are heart rate 118118 bpm, blood pressure 98/6298/62 mmHg, and respiratory rate 2424/min. Which of the following is the priority nursing action to reduce the client's risk for physiological deterioration?

  1. Initiate large-bore intravenous access and prepare for rapid isotonic fluid volume expansion.Cevap
  2. B
    Position the client upright at a 9090-degree angle to maximize diaphragmatic excursion.
  3. C
    Administer the prescribed as-needed intravenous opioid to manage the acute somatic and referred pain.
  4. D
    Palpate the abdomen deeply to identify the specific area of maximum rebound tenderness.

Cevap

The priority action is to initiate large-bore intravenous access and prepare for rapid isotonic fluid volume expansion to address impending hypovolemic shock.
The correct answer addresses the immediate life-threatening complication of hypovolemic shock resulting from internal bleeding. The client is demonstrating Kehr's sign (left shoulder pain caused by diaphragmatic irritation from intraperitoneal blood, classically seen in splenic rupture) alongside compensatory shock symptoms (restlessness, diaphoresis, tachycardia, and hypotension). Establishing large-bore IV access to facilitate rapid fluid and blood replacement is the priority action to maintain tissue perfusion and reduce the risk of mortality.

Adım Adım Çözüm

1
Analyze the client's history and presenting clinical symptoms.
The client has blunt abdominal trauma, new left shoulder pain (Kehr's sign), restlessness, diaphoresis, tachycardia (118118 bpm), and hypotension (98/6298/62 mmHg).
Recognizing patterns in clinical presentation is necessary to identify the potential complication.
2
Correlate the assessment findings with potential pathophysiological processes.
The combination of referred shoulder pain and signs of systemic hypoperfusion indicates a high probability of a ruptured spleen and internal hemorrhage.
Kehr's sign is caused by blood irritating the diaphragm, and the vital sign changes reflect early compensatory mechanisms for hypovolemic shock.
3
Prioritize nursing actions using the Airway, Breathing, Circulation (ABC) framework.
The most immediate life-threatening issue is circulatory collapse from active internal blood loss.
Without adequate intravascular volume, the client will rapidly progress to uncompensated shock and multisystem organ failure.
4
Determine the most appropriate immediate intervention to stabilize circulation.
Securing large-bore IV access for the administration of isotonic fluids or blood products is the highest priority.
Rapid volume resuscitation is required to maintain perfusion while preparing the client for definitive surgical intervention.

Anahtar Kavram

Early Recognition of Hemorrhagic Shock and Spleen Rupture
Tahmini Süre:1m 30s
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Konular

Reduction of Risk Potential

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