A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

Diminished breath sounds

Distended neck veins

Irregular heart rate

Itching over the incision

Answer and Explanation

The Correct Answer is A

A. Diminished breath sounds: A pneumothorax occurs when air accumulates in the pleural space, leading to lung collapse. This results in reduced air entry, causing diminished or absent breath sounds on the affected side. Other symptoms may include dyspnea, tachypnea, and chest pain.

B. Distended neck veins: Neck vein distention is more commonly associated with conditions such as cardiac tamponade or superior vena cava syndrome. A pneumothorax typically causes respiratory distress rather than venous congestion. If a tension pneumothorax develops, neck vein distention may occur, but it is not an early or primary sign.

C. Irregular heart rate: While severe cases of pneumothorax can cause cardiovascular compromise due to pressure on the heart and great vessels, an irregular heart rate is not a direct or early indicator. Cardiac arrhythmias are more often seen with electrolyte imbalances, cardiac ischemia, or other primary heart conditions.

D. Itching over the incision: Itching at the catheter insertion site is a common postoperative reaction, often related to healing, adhesive irritation, or mild inflammation. It is not indicative of a pneumothorax, which primarily presents with respiratory distress and absent or diminished breath sounds.

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Correct Answer is C

Explanation

A. "I cook my partner's favorite foods.": Preparing meals can be a way to show love and care, but it does not necessarily indicate effective coping. It may serve as a distraction, but it does not address emotional or social well-being.

B. "I make a list of all the things I need to do.": Creating lists can help with organization, but it does not directly reflect emotional coping. It may indicate a focus on tasks rather than emotional processing or seeking support.

C. "I have lunch with my friends once a week.": Maintaining social connections is a sign of effective coping, as it provides emotional support and an opportunity to share feelings. Engaging in enjoyable activities outside of caregiving responsibilities helps reduce stress.

D. "I am unable to fall asleep right away.": Difficulty sleeping is a common response to stress but suggests ongoing emotional distress rather than effective coping. Persistent sleep disturbances may require further assessment and support.

A. Apply dressing to foot wound. B. Consult outpatient wound care specialist. C. Schedule appointment with ophthalmologist. D. Administer regular insulin 4 units subcutaneously x 1 dose

Correct Answer is D

Explanation

Apply dressing to foot wound: While wound care is important, managing hyperglycemia takes priority. High blood glucose impairs wound healing and increases infection risk, making insulin administration the more urgent intervention. Dressing application should follow glycemic control measures.

Consult outpatient wound care specialist: A wound care consultation is appropriate for managing a chronic ulcer, but immediate intervention is required to stabilize glucose levels. Optimizing wound care should come after initial glucose management.

Schedule appointment with ophthalmologist: Clients with diabetes require routine eye exams due to the risk of diabetic retinopathy. However, addressing hyperglycemia and preventing further infection are more urgent concerns at this time.

Administer regular insulin 4 units subcutaneously x 1 dose: The client's blood glucose is elevated (250 mg/dL), which can impair immune function and tissue healing. Lowering glucose with insulin is the priority to prevent complications such as worsening infection or ketoacidosis.

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A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

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