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: Monitoring blood pressure (option C) is the most important additional assessment. The symptoms described indicate the possibility of autonomic dysreflexia, which can lead to dangerously high blood pressure and requires immediate attention.

Step-by-step solution

Understand the symptoms and complications related to thoracic fracture

A thoracic fracture can lead to various complications, including respiratory and cardiovascular issues, neurological damage, and impaired bowel function. The symptoms mentioned in this exercise, such as an intact halo device, flushing of the face and upper chest area, goose bumps, and a stuffy nose, could potentially be related to these complications.

Analyze each assessment option

A. Breath sounds: Assessing breath sounds is important as respiratory complications may arise due to thoracic fractures, such as pneumothorax, hemothorax, or reduced lung function. B. Deep tendon reflexes: Assessing deep tendon reflexes is crucial in evaluating the neurological status of the patient and identifying any potential neurological damage caused by the fracture. C. Blood pressure: Monitoring blood pressure is essential as it can help identify cardiovascular complications, such as hypotension or circulatory shock. The flushing and goosebumps might indicate autonomic dysreflexia which is an exaggerated reflex response which leads to high blood pressure. D. Bowel sounds: Assessing bowel sounds is relevant in identifying potential gastrointestinal complications, such as ileus or bowel obstruction. However, this may not be the primary concern based on the symptoms presented.

Determine the most important assessment

From the analysis of each option in step 2, it becomes clear that assessing blood pressure (option C) would be the most important additional assessment at this time. The symptoms described indicate the possibility of autonomic dysreflexia, which can lead to dangerously high blood pressure and requires immediate attention. Other assessments should still be performed, but blood pressure should be prioritized in this situation.