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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:

Air cannot pass freely into the thoracic cavity through a chest wound is incorrect because air can indeed pass freely into the thoracic cavity through the chest wound in an open pneumothorax.

Choice B Reason:

The air is trapped when it enters the cavity is incorrect because the characteristic feature of an open pneumothorax is that air is not trapped; rather, it enters the thoracic cavity with each inhalation and exits with each exhalation through the chest wound.

Choice C Reason:

Air moves in and out of a wound in the chest wall is correct. In an open pneumothorax, also known as a "sucking chest wound," air can freely move in and out of the thoracic cavity through a wound in the chest wall. This occurs due to the creation of a communication pathway between the external environment and the pleural space, typically caused by a penetrating injury to the chest.

Choice D Reason:

There are no audible sounds in an open pneumothorax is incorrect because in an open pneumothorax, there may be audible sounds associated with the movement of air in and out of the wound, such as a sucking or bubbling sound, depending on the size and location of the wound. These sounds can be clinically significant and aid in the diagnosis of an open pneumothorax.

A. Light sensitivity B. Loss of consciousness C. A dilated pupil D. Visual disturbances E. Nausea and vomiting F. Numbness on one side of the face

Correct Answer is ["B","C","D","E"]

Explanation

Choice A Reason:

Light sensitivity is incorrect. Light sensitivity (photophobia) is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur as a secondary symptom due to other neurological disturbances or increased intracranial pressure.

Choice B Reason:

Loss of consciousness is correct. Loss of consciousness is a common manifestation of a ruptured cerebral aneurysm, particularly if the bleeding leads to significant brain injury or compression of vital brain structures.

Choice C Reason:

A dilated pupil is correct. A dilated pupil (mydriasis) may occur as a result of compression of the oculomotor nerve (cranial nerve III) by the expanding hematoma or increased intracranial pressure following a ruptured cerebral aneurysm.

Choice D Reason:

Visual disturbances is correct. Visual disturbances, such as blurred vision, double vision (diplopia), or loss of vision, may occur due to compression of the optic nerve or damage to visual pathways as a result of the hemorrhage.

Choice E Reason:

Nausea and vomiting is correct. Nausea and vomiting are common symptoms associated with a ruptured cerebral aneurysm, often due to irritation of the meninges and increased intracranial pressure resulting from the bleeding.

Choice F Reason:

Numbness on one side of the face is incorrect. Numbness on one side of the face is not typically a direct manifestation of a ruptured cerebral aneurysm. However, it may occur if the hemorrhage affects specific regions of the brain responsible for sensation or if there is associated compression of cranial nerves.

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A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

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Which of the following is true regarding the physiology of an open pneumothorax?

Correct Answer is C

Explanation

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