The nurse is assessing a school-age client who experienced blunt force trauma to the chest when an airbag deployed following a motor vehicle crash. Which areas of assessment are essential for this client?
1. Monitor responsiveness and behavior.
2. Monitor SpO2.
3. Auscultate the lungs for crackles, wheezes, decreased breath sounds.
4. Document input and output.
5. Note changes in voice quality or coughing.
Correct Answer: 1,2,3,4
Rationale: The areas of assessment that are essential for this client include: monitoring for responsive and behavior in order to detect hypoxia and the potential for airway obstruction; monitoring SpO2 frequently to identify changes indicating deterioration in condition; auscultating the lungs for crackles, wheezes, decreased breath sound; and noting changes in voice quality or coughing. Documenting input and output is not a priority for this client.
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