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Question 1 of 1
1. Question
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?
Correct
Option 3 is the correct answer:
Rationale:Flail chest results from multiple rib fractures. This results in a “floating” section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
Test-Taking Strategy: Note the strategic word, most. Cyanosis and hypotension occur with many different disorders, so eliminate options 1 and 2 first. From the remaining options, choose paradoxical chest movement over dyspnea on exhalation by remembering that a flail chest has broken rib segments that move independently of the rest of the rib cage.
Incorrect
Option 3 is the correct answer:
Rationale:Flail chest results from multiple rib fractures. This results in a “floating” section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
Test-Taking Strategy: Note the strategic word, most. Cyanosis and hypotension occur with many different disorders, so eliminate options 1 and 2 first. From the remaining options, choose paradoxical chest movement over dyspnea on exhalation by remembering that a flail chest has broken rib segments that move independently of the rest of the rib cage.
Flail chest
Description
Flail Chest Occurs from blunt chest trauma associated with accidents, which may result in hemothorax and rib fractures.
The loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall.
Nursing Assessment:
Paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration)
