Question

A nurse in a pediatric emergency department is planning care for an adolescent.

based on the information in the adolescent's medical record, which of the following actions should the nurse plan to take?

nurse's notes:
2245:
- adolescent arrived via stretcher by EMT following a motor-vehicle crash.
EMT personnel report:
- client was found conscious at the scene inside of the vehicle with airbag deployed, wearing a seat belt.
- vital signs: heart rate 94/min, respiratory rate 20/min, blood pressure 100/60 mmHg.
- 18-gauge peripheral IV inserted in left antecubital.
- guardians contacted and report the child has no medical conditions.
2300:
- adolescent reports sharp pain in chest.
- rates pain as a 6 on a scale of 0 to 10.
- respirations fast and shallow.
- diminished breath sounds in left lung.
- S1 and S2 regular and rapid.

2300 vital signs:
- temperature: 38.0 C (100.4 F).
- heart rate: 110/min.
- respiratory rate: 30/min.
- blood pressure: 90/60 mmHg.
- oxygen saturation: 94% on room air.

diagnostic results:
- chest x-ray: air present in left pleural space; suggestive of pneumothorax. CT scan recommended for definitive diagnosis.

Answer 1

The nurse should take immediate action due to symptoms and diagnostic results suggesting pneumothorax in the adolescent.

Step-by-step explanation:

Based on the information in the adolescent's medical record, the nurse should plan to take immediate action due to the presence of symptoms and diagnostic results that suggest the adolescent may have a pneumothorax. The adolescent arrived in the emergency department following a motor-vehicle crash and reported sharp pain in the chest. The physical examination revealed diminished breath sounds in the left lung, and the chest x-ray indicated air in the left pleural space. A CT scan is recommended for definitive diagnosis.