A nurse is caring for a client who takes lisinopril for hypertension. Which of the following client statements indicates an adverse effect of the medication?

Findings that indicate the client has a potential problem:

• Chest pain radiating to left arm: Chest pain that radiates to the left arm is a classic symptom of a myocardial infarction (MI). The description of pain (tightness) and its radiation to the left arm are a red flag for an acute cardiac event, which requires immediate intervention.
• Pain level of 7 on a scale of 0 to 10: A pain level of 7 indicates significant discomfort, and when combined with other symptoms like chest tightness and radiation to the left arm, it further supports the possibility of a myocardial infarction.
• Started to feel nauseous after breakfast: Nausea can be an associated symptom of acute myocardial infarction (MI), especially in women, the elderly, and those with diabetes. Its presence, along with chest pain, is concerning.
• Diaphoresis: Diaphoresis (excessive sweating) is often associated with myocardial infarction and is a key sign of acute coronary syndrome. This finding, along with chest pain and shortness of breath, suggests an emergent situation.
• Tachycardia with irregular heart rate: The client’s heart rate is 110/min and irregular, which can be indicative of arrhythmias commonly seen in acute myocardial infarction. The irregular and tachycardic rhythm should be immediately evaluated to prevent further complications.
• +1 pedal pulses: While present, +1 pedal pulses are diminished. This could indicate compromised peripheral circulation, possibly related to overall cardiovascular compromise or underlying peripheral artery disease, which is often co-morbid with the client's existing conditions (hyperlipidemia, hypertension, diabetes).
• Skin is cool to touch: Cool skin, especially when accompanied by other signs of poor perfusion like diminished pulses, can indicate reduced peripheral blood flow, which may be a systemic response to decreased cardiac output from a significant cardiac event.

Rationale for Incorrect Findings:

• Lungs clear to auscultation: Clear lung sounds suggest no signs of pulmonary edema or other lung issues at the moment, ruling out respiratory causes of the symptoms.
• Bowel sounds present in all 4 quadrants: The presence of bowel sounds in all quadrants is normal and suggests that the gastrointestinal system is functioning well.
• Capillary refill less than 2 seconds is normal and indicate adequate perfusion, this finding on its own does not require follow up.

Rationale:

A. Irregular heart rate: An irregular heart rate can indicate various conditions, including electrolyte imbalances or arrhythmias, but it is not a specific sign of a pneumothorax. It is more commonly associated with cardiac issues.

B. Itching over the incision: Itching at the incision site may be a result of an allergic reaction, irritation, or healing, but it is not a typical sign of pneumothorax. Pneumothorax symptoms are more related to respiratory and circulatory changes.

C. Distended neck veins: Distended neck veins can indicate various conditions, such as heart failure or fluid overload, but it is not a classic sign of pneumothorax. A pneumothorax usually causes changes in respiratory status rather than venous distention.

D. Diminished breath sounds: Diminished breath sounds are a hallmark sign of a pneumothorax. A pneumothorax occurs when air enters the pleural space, causing lung collapse. This leads to decreased lung sounds on the affected side.