What will the nurse expect to assess in a patient with a tension pneumothorax?
1. Tracheal deviation to the unaffected side
2. Bilateral equal chest movement
3. Decreased muscular effort by chest muscles
4. Decreasing central venous pressure (CVP)
1
Rationale 1: As air accumulates on the pleural space with no place to escape, the affected lung collapses and the resulting increase on intrathoracic pressure puts pressure on the trachea, which causes displacement to the unaffected side.
Rationale 2: Normal breathing is bilaterally equal. In a tension pneumothorax, one or more areas of the lung tissue collapses and does not expand, therefore limiting the chest movement on that side. Therefore, the movement is bilaterally unequal.
Rationale 3: Increased muscle effort will be the response to decreasing lung activity. Extra muscles of the chest are called into place to try to increase the effort to move the air within the lung tissues.
Rationale 4: The CVP will increase to try to compensate for decreased pulmonary perfusion from a decrease in the surface area for oxygen to be exchanged.
You might also like to view...
A patient is to receive desmopressin for diabetes insipidus. By which routes may the drug be administered? You may select more than one answer
a. By mouth b. IV c. By nasal spray d. Subcutaneously e. IM
A patient comes to the clinic complaining of excruciating pain on one side of the face. What should the nurse suspect is occurring with this patient?
1. trigeminal neuralgia 2. Parkinson disease 3. Bell palsy 4. myasthenia gravis
Which of the following nursing assessment questions will best determine the nature of an exer-cise-related injury?
1. "Do you experience the pain during or after your workout?" 2. "Tell me what is included in your typical workout routine." 3. "How long does it hurt after you have stopped exercising?" 4. "On a scale of 1 to 10, please rate your postexercise pain for me."
A patient with depression does not want to take prescribed medication because of the side effects. What can the nurse suggest to help with medication adherence? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. Use ice chips to help alleviate dry mouth. 2. Chew gum or use hard candy to help alleviate dry mouth. 3. Avoid alcohol-based mouthwash to help alleviate dry mouth. 4. Use "dry eye" drops to help with eye dryness. 5. Ask the pharmacist to fill the prescription with the same drug from a different manufacturer.