Question

A client is on the neurological unit after a sports injury resulting in a thoracic fracture. The nurse's assessment reveals an intact halo device, flushing of the face and upper chest area, goose bumps, and a stuffy nose. What additional assessment would be most important at this time? A. Breath sounds B. Deep tendon reflexes C. Blood pressure D. Bowel sounds

Short answer

Answer: Breath sounds.

Step-by-step solution

Analyzing the provided information

The patient is in the neurological unit after a sports injury, which led to a thoracic fracture. The intact halo device indicates that the fracture has been stabilized. However, we need to look into any possible complications that may arise due to the injury or its treatment.

Evaluate Option A - Breath sounds

Considering the thoracic injury, it is essential to assess the breath sounds, because the client's respiration might be affected by the injury. This is important to ensure proper oxygenation and monitor for any chest complications.

Evaluate Option B - Deep tendon reflexes

Deep tendon reflexes could provide information about the client's neurological function, which could be relevant, given the sports injury. However, it may not provide direct information about any acute complications related to the thoracic fracture.

Evaluate Option C - Blood pressure

Blood pressure can be an important assessment for this client to determine if the injury might have impacted the cardiovascular system. Flushing and stuffiness might be indicative of compromised blood flow, so monitoring blood pressure would be important to rule out any complications or to monitor the effects of any treatment.

Evaluate Option D - Bowel sounds

Although bowel sounds might be an important aspect of the overall assessment for the client's health, it may not have a direct relationship with the client's thoracic injury or the other symptoms mentioned, such as flushing, goosebumps, and stuffy nose.

Choosing the most important assessment at this time

Given the thoracic injury and the patient's current symptoms, the most important assessment in this scenario would be Option A - Breath sounds. This is crucial due to the client's location in the neurological unit, the thoracic injury, and the need to monitor for potential complications related to respiration. We will discard options B, C, and D as less relevant in this context. So the correct answer is A. Breath sounds.