A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Choice A rationale:

(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.

Choice B rationale:

Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.

Choice C rationale:

Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.

Choice D rationale:

Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.

Choice A rationale:

Unequal chest expansion is the correct choice. In a patient with chronic obstructive pulmonary disease (COPD), the airways are often narrowed and obstructed, leading to difficulty in moving air in and out of the lungs. This can result in unequal chest expansion during breathing, where one side of the chest expands less than the other. This finding is commonly observed in patients with COPD due to the imbalance in lung function between different areas of the lungs.

Choice B rationale:

Atrophied neck and trapezius muscle is not a typical finding in COPD. Muscle atrophy can occur in conditions of prolonged disuse or immobility, but it is not a characteristic manifestation of COPD itself.

Choice C rationale:

Increased tactile fremitus refers to increased vibrations felt on the chest wall during speech. This finding is more commonly associated with conditions that cause lung consolidation, such as pneumonia. In COPD, there is often air trapping and hyperinflation of the lungs, which would not lead to increased tactile fremitus.

Choice D rationale:

An anterior-to-posterior chest diameter ratio of 1:1 is not a typical finding in a healthy individual, let alone in a patient with COPD. In COPD, there is often an increase in the anterior-to-posterior chest diameter ratio, giving the chest a barrel-like appearance. This is due to the trapped air and hyperinflation of the lungs, which is characteristic of the disease.