A client presents to the emergency room reporting sudden, sharp pain on the right side of the chest and shortness of breath. The right side of the chest is not moving with inspiration. The client's trachea is deviated towards the left: there is absence tactile fremitus on the right side of the chest. Upon percussion, the nurse hears hyperresonant sound on the right side of the thorax. Upon auscultation, no breath sounds are heard on the right. Which disorder would the nurse suspect?
Asthma.
Pneumothorax.
Atelectasis.
Pneumonia.
The Correct Answer is B
Choice A rationale:
Asthma - Asthma is a chronic respiratory condition characterized by bronchoconstriction, inflammation, and increased mucus production. It does not typically present with absent breath sounds, deviation of the trachea, or hyperresonant percussion sounds. Wheezing is a common finding in asthma.
Choice B rationale:
Pneumothorax - This is the correct choice. The scenario describes classic signs of a tension pneumothorax, which is a medical emergency. The tracheal deviation, absence of breath sounds, and hyperresonant percussion note on the affected side are indicative of air accumulation in the pleural space, leading to lung collapse and displacement of mediastinal structures.
Choice C rationale:
Atelectasis - Atelectasis refers to the collapse or incomplete expansion of a lung or part of a lung. It can lead to decreased breath sounds on auscultation but does not usually cause tracheal deviation or hyperresonance on percussion. It is not the best fit for the described signs.
Choice D rationale:
Pneumonia - Pneumonia is an infection of the lung tissue that can cause symptoms like fever, cough, and productive sputum. Breath sounds may be diminished over the affected area due to consolidation, but the absence of breath sounds, tracheal deviation, and hyperresonance point more strongly toward a pneumothorax in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.
Choice B rationale:
Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.
Choice C rationale:
Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.
Choice D rationale:
Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.
Correct Answer is D
Explanation
Choice A rationale:
Hypotension is not an expected manifestation of hypoxemia during an asthma attack. Hypotension refers to abnormally low blood pressure. During an asthma attack, the body's response to hypoxemia is more likely to involve increased heart rate (tachycardia) as the heart attempts to compensate for decreased oxygen levels.
Choice B rationale:
Dysphagia is not directly related to hypoxemia during an asthma attack. Dysphagia refers to difficulty swallowing, which is not a typical respiratory manifestation. Hypoxemia in asthma is more likely to lead to symptoms such as shortness of breath, wheezing, and increased work of breathing.
Choice C rationale:
Peripheral edema is not a typical manifestation of hypoxemia during an asthma attack. Peripheral edema, or swelling in the extremities, can occur in conditions like heart failure but is not directly related to the airway constriction and reduced oxygen exchange seen in asthma attacks.
Choice D rationale:
Agitation is the correct choice. Hypoxemia, which occurs when there is a decrease in the oxygen levels in the blood, can lead to inadequate oxygen supply to the brain. This can result in neurological symptoms such as agitation, restlessness, confusion, and even loss of consciousness. Agitation is a manifestation of the body's attempt to cope with the lack of oxygen.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.