Question

The nurse is caring for a client in the emergency room who is admitted after an MVA. Which assessment finding best indicates a possible spleen rupture? A. Diminished bowel sounds B. BP \(120 / 70\), pulse rate 100 , respiration 18 C. Ballance's sign D. Wheezing on chest auscultation

Short answer

Answer: Ballance's sign

Step-by-step solution

Define spleen rupture and its symptoms

A spleen rupture is a medical condition where the spleen (an organ involved in producing and clearing blood cells, and forming part of the immune system) is damaged and starts to bleed. Symptoms can include abdominal pain, tenderness, and swelling, left shoulder pain, rapid heart rate, dizziness, and low blood pressure.

Evaluate Option A

Diminished bowel sounds might indicate a gastrointestinal issue, but it does not directly indicate a spleen rupture. Although abdominal pain could be present in both cases, diminished bowel sounds are not specific to a spleen rupture.

Evaluate Option B

Blood pressure 120/70, pulse rate 100, and respiration 18 are relatively normal vital signs on its own and do not necessarily suggest a spleen rupture. However, it is worth noting that an increased heart rate may be present in cases with spleen rupture due to bleeding.

Evaluate Option C

Ballance's sign is a medical sign found in patients with a ruptured spleen. It is characterized by dullness to percussion (tapping) of the left upper abdomen, along with shifting dullness to the right side when the patient is lying on their left side. This sign is indicative of internal bleeding, which is a feature of a ruptured spleen.

Evaluate Option D

Wheezing on chest auscultation is generally associated with respiratory issues and is not directly indicative of a spleen rupture.

Choose the best option

Of the four assessment findings, option C, Ballance's sign, is the most indicative of a spleen rupture. This is because it is directly related to internal bleeding and is a well-known sign typically associated with ruptured spleens.