Which assessment finding indicates a tension pneumothorax, a complication of untreated pneumothorax?

Symmetrical chest expansion.

Tracheal deviation away from the affected side.

Increased breath sounds on the affected side.

Hyperresonance to percussion on the affected side.

Answer and Explanation

The Correct Answer is B

A. Symmetrical chest expansion: In a tension pneumothorax, chest expansion is usually asymmetrical because air trapped in the pleural space prevents full lung expansion on the affected side. Symmetrical movement would not be expected in this condition.

B. Tracheal deviation away from the affected side: This is a hallmark sign of tension pneumothorax. As intrapleural pressure increases, the mediastinum shifts, pushing the trachea and other structures toward the unaffected side, which is a medical emergency requiring immediate intervention.

C. Increased breath sounds on the affected side: Breath sounds are typically absent or markedly diminished over the affected lung due to lung collapse. Increased breath sounds would not occur in the presence of trapped air compressing the lung.

D. Hyperresonance to percussion on the affected side: Hyperresonance can occur with a simple pneumothorax due to excess air in the pleural cavity. However, while present, it is not as specific or critical as tracheal deviation, which directly indicates a tension pneumothorax.

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Correct Answer is C

Explanation

A. Depressive characteristics of schizophrenia: While some atypical antipsychotics may have mood-stabilizing effects, paliperidone is not primarily indicated for treating depressive symptoms. Antidepressants are more effective for depressive features rather than antipsychotic agents.

B. Negative symptoms of schizophrenia only: Paliperidone helps address negative symptoms such as social withdrawal and blunted affect, but it is not limited to these alone. Its mechanism of action also targets positive symptoms, making this option incomplete.

C. Both positive and negative symptoms of schizophrenia: Paliperidone, an atypical antipsychotic, blocks dopamine D2 receptors and serotonin 5-HT2A receptors. This dual action makes it effective for reducing hallucinations and delusions (positive symptoms) as well as improving motivation and affect (negative symptoms).

D. Low serotonin levels: Paliperidone does act on serotonin receptors, but it does not treat “low serotonin levels” as a standalone condition. Instead, the benefit is its balanced effect on both dopamine and serotonin pathways, reducing positive and negative symptoms in schizophrenia.

A. Place the head of the patient's bed flat. B. Notify the healthcare provider. C. Milk the chest tube. D. Disconnect the system and get another.

Correct Answer is B

Explanation

A. Place the head of the patient's bed flat: Positioning the patient flat does not address the underlying issue of excessive bubbling. This intervention has no effect on the integrity of the chest tube system or on resolving the possible air leak.

B. Notify the healthcare provider: Excessive bubbling in the water seal chamber usually indicates an air leak in the chest tube system or from the patient’s lung. Prompt notification of the healthcare provider ensures timely evaluation and correction of the problem to prevent complications.

C. Milk the chest tube: Milking or stripping chest tubes is not recommended because it can create high negative pressures and damage lung tissue. This action does not correct excessive bubbling and may worsen patient outcomes.

D. Disconnect the system and get another: Disconnecting the system increases the risk of introducing air into the pleural space, potentially leading to a tension pneumothorax. Replacing the system may be needed, but it should not be done before assessing and notifying the healthcare provider.

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Which assessment finding indicates a tension pneumothorax, a complication of untreated pneumothorax?

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Naxlex Comprehensive Predictor Exams

A major advantage of giving the antipsychotic drug Invega/paliperidone is that it is effective against what symptoms?

Correct Answer is C

Explanation

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Correct Answer is B

Explanation

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