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 B
Explanation
Choice A Reason:
A client with a decreased potassium level is incorrect. Hypokalemia (decreased potassium level) can cause various neurological symptoms, but it doesn't directly lead to osmotic cerebral edema.
Choice B Reason:
When plasma glucose levels are rapidly lowered, an osmotic gradient develops between the brain and plasma, which can lead to cerebral edema.Brain cells pull water from the plasma, resulting in widespread edema.
Choice C Reason:
While HbA1c is an important marker of diabetes control and may indicate poor long-term management, it does not directly relate to the acute metabolic derangements (e.g., rapid osmotic shifts, severity of acidosis) that predispose to cerebral edema in DKA.
Choice D Reason:
A client with an increased creatinine level is incorrect. Elevated creatinine levels typically indicate kidney dysfunction or dehydration, but they don't directly cause osmotic cerebral edema.
Correct Answer is D
Explanation
Choice A Reason:
Weight loss is inappropriate. Weight loss can occur in individuals with COPD, particularly in advanced stages of the disease. Factors contributing to weight loss may include decreased appetite, increased energy expenditure due to labored breathing, and muscle wasting.
Choice B Reason:
Poor nutrition is inappropriate. Poor nutrition is a significant risk factor in COPD. Individuals with COPD may experience difficulties with eating due to dyspnea, fatigue, and reduced appetite. Malnutrition can lead to muscle weakness, decreased immune function, and worsened respiratory status.
Choice C Reason:
Muscle dysfunction is inappropriate: Muscle dysfunction, particularly skeletal muscle dysfunction, is common in COPD. Reduced physical activity, systemic inflammation, oxidative stress, and metabolic abnormalities contribute to muscle wasting and weakness in individuals with COPD.
Choice D Reason
.Increased risk for pneumonia is incorrect. Individuals with COPD are at an increased risk for respiratory infections, including pneumonia. COPD-related factors such as impaired mucociliary clearance, airway inflammation, and reduced lung function predispose patients to respiratory infections.
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