Question

a nurse is caring for the client who has a primary spontaneous pneumothorax. which of the following manifestations should the nurse expect to observe? (select all that apply.)
severe chest pain radiating to the shoulder
shortness of breath
jugular vein distention
severe dyspnea
cyanosis

Explanation:

• Severe chest pain radiating to the shoulder: In primary spontaneous pneumothorax, air accumulates in the pleural space. This can cause irritation and pain that may radiate, so this manifestation is expected.
• Shortness of breath: With air in the pleural space, the lung's ability to expand is compromised. This leads to reduced gas exchange, resulting in shortness of breath.
• Jugular vein distention: This is more associated with conditions like right - sided heart failure or cardiac tamponade. In primary spontaneous pneumothorax (unless it progresses to a tension pneumothorax which is a different entity in terms of pathophysiology and is not the case for a simple primary spontaneous pneumothorax here), jugular vein distention is not a typical manifestation.
• Severe dyspnea: Similar to shortness of breath, the presence of air in the pleural space impairs normal lung function. As the pneumothorax can reduce the functional residual capacity and ventilation - perfusion mismatch, severe dyspnea can occur.
• Cyanosis: When there is significant impairment of oxygenation (due to the compromised lung function from the pneumothorax), cyanosis (a bluish discoloration of the skin and mucous membranes due to reduced oxygen - hemoglobin saturation) can be observed.

Answer:

• Severe chest pain radiating to the shoulder
• Shortness of breath
• Severe dyspnea
• Cyanosis