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 C
Explanation
Choice A Reason:
"Antibiotics are seldom prescribed," is not an appropriate response as it does not address the client's concern about the cost of medication and may also be inaccurate depending on the specific diagnosis and treatment plan.
Choice B Reason:
"Maybe you can borrow some money to get the medicine," may not be feasible for the client and can also be perceived as insensitive or dismissive of their financial situation.
Choice C Reason:
"Your health care provider may be able to give you free samples. “offers a compassionate and practical solution to the client's concern about the cost of medication. Many healthcare providers have access to free medication samples provided by pharmaceutical companies, which they can offer to patients who have financial difficulties.
Choice D Reason:
"Where did your money go this month?" is judgmental and inappropriate. It may make the client feel ashamed or defensive about their financial situation, which is not conducive to a therapeutic nurse-client relationship. Additionally, the client's financial decisions are not relevant to their need for medical treatment.
Correct Answer is ["B","D","E","F"]
Explanation
Choice A Reason:
Client responds to name is incorrect. Responding to one's name is a positive sign indicating consciousness and orientation. It suggests that the client's level of consciousness is relatively intact.
Choice B Reason:
Eyes open to painful stimuli is correct. Opening the eyes in response to painful stimuli is a concerning sign, indicating a decrease in consciousness and potentially worsening neurological status. It suggests that the client's level of arousal is diminishing and may indicate a decline in condition.
Choice C Reason:
Client states day of the week is correct. Oriented behavior, such as knowing the day of the week, is a positive sign indicating intact cognition and orientation. It suggests that the client's mental status is relatively preserved.
Choice D Reason:
Client is confused is correct. Confusion is a concerning sign, indicating altered mental status and potentially worsening neurological function. It suggests that the client's cognition is impaired, which may be indicative of a decline in condition.
Choice E Reason:
Client mumbles inappropriate words is correct. Mumbling inappropriate words suggests disorientation and altered mental status, which are concerning signs indicating a decline in neurological function.
Choice F Reason:
Eyes do not open to name is incorrect. Failure to open the eyes in response to verbal stimuli, such as one's name, is a concerning sign indicating a decrease in consciousness and potentially worsening neurological status. It suggests that the client's level of arousal is diminished and may indicate a decline in condition.
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