A nurse is caring for a client who has Alzheimer's disease.
Which of the following findings should the nurse expect?

The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.

Choice A rationale:

Paradoxical chest movement refers to the abnormal inward movement of the chest during inhalation and outward movement during exhalation. It is not a typical finding in pneumothorax. Instead, paradoxical chest movement is often observed in conditions such as flail chest.

Choice B rationale:

Reduced right-sided breath sounds are a common finding in right pneumothorax. Air in the pleural space can cause lung collapse, leading to decreased or absent breath sounds on the affected side.

Choice C rationale:

High-pitched stridor is a sound heard during inspiration and indicates upper airway obstruction, often due to conditions like croup or epiglottitis. It is not a characteristic finding in pneumothorax.

Choice D rationale:

Intercostal retractions occur when the tissues between the ribs are pulled inward during inspiration. While retractions can be seen in various respiratory distress conditions, they are not specific to pneumothorax.