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 B
Explanation
Choice A rationale:
Restricting the client's fluid intake to less than 2 L/day is not an appropriate intervention for a client with COPD. Adequate hydration is important to help thin mucus secretions and improve respiratory function. Restricting fluids can lead to thicker mucus and exacerbate breathing difficulties.
Choice B rationale:
Instructing the client to use pursed-lip breathing is a beneficial intervention for someone with COPD. Pursed-lip breathing helps improve breathing efficiency by promoting better air exchange and preventing air trapping, which is common in COPD. It helps slow down breathing and increases oxygen saturation.
Choice C rationale:
Having the client use the early-morning hours for exercise and activity might not be the best choice. Morning hours can be when clients with COPD experience more respiratory symptoms. It's advisable to schedule activities during times when the client feels more comfortable and less breathless.
Choice D rationale:
Providing the client with a low-protein diet is not a relevant intervention for COPD management. COPD primarily affects the lungs and respiratory system, and a low-protein diet is not a standard part of its management. Nutritional recommendations for COPD typically focus on maintaining a balanced diet to support overall health.
Correct Answer is D
Explanation
Choice A rationale:
Decreased heart rate is not an anticipated finding in response to acute pain. Pain typically triggers sympathetic nervous system activation, leading to an increased heart rate as a physiological response to the stressor.
Choice B rationale:
Hyperactive bowel sounds are not typically associated with acute pain. Acute pain is more likely to induce a sympathetic response, which can lead to decreased gastrointestinal motility and hypoactive bowel sounds.
Choice C rationale:
Decreased blood pressure is not a common response to acute pain. Pain often leads to an increase in blood pressure due to the activation of the sympathetic nervous system and the release of stress hormones.
Choice D rationale:
Increased respiratory rate is the anticipated finding in response to acute pain. Acute pain can cause an increase in the sympathetic nervous system activity, leading to a higher respiratory rate as the body prepares for a fight-or-flight response. This increased respiratory rate helps oxygenate the blood and meet the potential increased demand for energy during stress.
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