When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?

Choice A rationale

Increasing the suction pressure would not address the underlying issue of an air leak and could potentially worsen the patient's condition by causing further lung collapse or trauma. Continuous bubbling in the water-seal chamber indicates a persistent air leak from the pleural space, tubing, or at the insertion site, which needs to be identified and resolved. Adjusting the suction without finding the source of the leak is an inappropriate intervention.

Choice B rationale

Clamping the chest tube is a dangerous intervention as it can lead to a tension pneumothorax, a life-threatening condition. Clamping prevents air and fluid from exiting the pleural space, causing pressure to build up and compress the lung, heart, and great vessels. This action should only be performed for very brief periods under specific, controlled circumstances, such as when changing the drainage system.

Choice C rationale

Continuous bubbling in the water-seal chamber is not a normal finding. Normal bubbling in this chamber should only occur intermittently with the patient's respirations, indicating the resolution of the pneumothorax. Continuous bubbling signifies an ongoing air leak, which requires investigation. The nurse must not document this as a normal finding but rather as an abnormal assessment that warrants immediate action.

Choice D rationale

Continuous bubbling in the water-seal chamber indicates a persistent air leak in the pleural space or the drainage system. The nurse must systematically check all connections from the insertion site to the drainage unit to identify and correct the source of the leak. The goal is to ensure the integrity of the closed system to prevent atmospheric air from entering the chest and to facilitate lung re-expansion.

Choice A rationale

In the initial stages of hypoxemia, the body's compensatory response involves activating the sympathetic nervous system to increase oxygen delivery. This sympathetic surge leads to vasoconstriction and an increase in heart rate, resulting in elevated blood pressure. This is a temporary mechanism to improve tissue perfusion and is a key early sign before the decompensation phase begins. Normal systolic blood pressure is less than 120 mmHg and diastolic is less than 80 mmHg.

Choice B rationale

Pale skin, or pallor, is an early and observable manifestation of hypoxemia. This is a result of peripheral vasoconstriction, a compensatory mechanism triggered by the sympathetic nervous system to shunt blood from the periphery to vital organs like the heart and brain. This reduction in peripheral blood flow leads to the skin appearing pale, particularly in the extremities and mucous membranes.

Choice C rationale

Confusion is an early and significant neurological sign of cerebral hypoxemia. The brain is highly sensitive to changes in oxygen levels. As oxygen saturation drops, cerebral function is impaired, leading to altered mental status, confusion, restlessness, and anxiety. This is one of the most reliable indicators of impending respiratory failure.

Choice D rationale

Hypotension is typically a late sign of hypoxemia, indicating a state of decompensation and impending circulatory collapse. As the body's compensatory mechanisms fail to maintain adequate cardiac output and oxygen delivery, the patient's blood pressure will drop. This is a critical and ominous finding, suggesting that the patient is in a state of shock and requires immediate intervention