A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?
Respiratory alkalosis
Increased venous return
Decreased cardiac output
Dilated ventricles
The Correct Answer is C
Choice A Reason:
Respiratory alkalosis is incorrect. Tension pneumothorax typically leads to respiratory distress and hypoxemia rather than respiratory alkalosis. The respiratory alkalosis may occur initially due to hyperventilation in response to hypoxemia but would not be directly related to tracheal deviation.
Choice B Reason:
Increased venous return is incorrect. Tension pneumothorax actually leads to decreased venous return due to compression of the great vessels in the thorax, particularly the superior vena cava and the inferior vena cava. This compression results from the increased pressure within the thorax, which impedes blood flow back to the heart.
Choice C Reason:
Decreased cardiac output is incorrect. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.
Choice D Reason:
Dilated ventricles is incorrect. As mentioned earlier, tension pneumothorax can lead to compression of the heart, including the ventricles. This compression can cause dilatation of the ventricles, particularly the right ventricle, due to increased afterload and decreased venous return.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A Reason:
Paresthesia is appropriate. Paresthesia, or abnormal sensations such as tingling, numbness, or burning, is a common neurological symptom in individuals with multiple sclerosis. It results from damage to the nerves or disruption of nerve signals in the central nervous system.
Choice B Reason:
Nausea and vomiting is inappropriate. While nausea and vomiting can occur in individuals with multiple sclerosis, they are not considered hallmark symptoms of the disease. These symptoms may be associated with other factors such as medications, autonomic dysfunction, or complications such as urinary tract infections.
Choice C Reason:
Dysphagia is appropriate. Dysphagia, or difficulty swallowing, is a common symptom in individuals with multiple sclerosis, particularly as the disease progresses. It can result from damage to the nerves that control swallowing muscles or from impaired coordination of swallowing reflexes.
Choice D Reason:
Spasticity is appropriate. Spasticity, or muscle stiffness and involuntary muscle contractions, is a common symptom in individuals with multiple sclerosis. It occurs due to damage to the nerve fibers that control muscle movement and can lead to difficulty with movement, walking, and muscle control.
Choice E Reason:
Vertigo is appropriate. Vertigo, or the sensation of spinning or dizziness, can occur in individuals with multiple sclerosis, particularly if lesions develop in areas of the brain involved in balance and coordination.
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
Genetics is correct. There is evidence to suggest that genetics play a role in the development of multiple sclerosis. Although no single gene has been identified as the cause of MS, certain genetic variations have been associated with an increased risk of developing the disease. Having a first-degree relative with MS increases an individual's risk, although the overall genetic contribution to MS susceptibility is thought to be relatively modest.
Choice B Reason:
Environmental factors is correct. Environmental factors are believed to play a significant role in the development of multiple sclerosis, particularly in individuals with a genetic predisposition. Factors such as vitamin D deficiency, smoking, exposure to certain infections (such as Epstein-Barr virus), and geographic location (latitude) have been implicated as potential triggers for MS development.
Choice C Reason:
Upper respiratory infections is incorrect. While infections may trigger exacerbations or relapses in individuals with existing multiple sclerosis, there is limited evidence to suggest that upper respiratory infections contribute directly to the development of MS. However, some research suggests that viral infections, particularly those occurring during childhood or adolescence, may influence the risk of developing MS later in life.
Choice D Reason:
Autoimmune factors is correct. Multiple sclerosis is widely recognized as an autoimmune disease, characterized by immune-mediated inflammation and damage to the central nervous system. In MS, the immune system mistakenly attacks myelin, the protective covering of nerve fibers, leading to demyelination and neurological dysfunction. Autoimmune factors are therefore considered central to the pathogenesis of MS.
Choice E Reason:
Urinary tract infections is incorrect. While urinary tract infections (UTIs) are common in individuals with multiple sclerosis due to bladder dysfunction associated with the disease, there is no direct evidence to suggest that UTIs contribute to the development of MS.
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