A nurse is assessing a client who has a possible right pneumothorax.
Which of the following findings should the nurse expect?
A.
Paradoxical chest movement.
B.
Reduced right-sided breath sounds.
C.
High-pitched stridor.
D.
Intercostal retractions.
The Correct Answer and Explanation is:
The correct answer is B. Reduced right-sided breath sounds.
A pneumothorax occurs when air accumulates in the pleural space, causing the lung on the affected side to collapse partially or completely. This leads to decreased or absent breath sounds on the side where the pneumothorax is present. In this case, since the client has a possible right-sided pneumothorax, the nurse should expect reduced or absent breath sounds on the right side.
Explanation:
When air enters the pleural space, the lung cannot fully expand during inhalation, leading to a loss of the normal breath sounds in that area. The affected side will have diminished or absent breath sounds because air in the pleural space impedes normal lung movement and function.
Let’s look at the other options to understand why they are incorrect:
A. Paradoxical chest movement
Paradoxical chest movement is a hallmark sign of a flail chest, not a pneumothorax. In flail chest, part of the ribcage moves in the opposite direction of the rest of the chest during breathing due to fractures in multiple consecutive ribs. This would not be seen in a client with a pneumothorax.
C. High-pitched stridor
Stridor is a high-pitched sound usually heard during inspiration and is often a sign of an upper airway obstruction, such as from laryngeal or tracheal narrowing. A pneumothorax affects the lungs and pleural space rather than the upper airway, so stridor is not expected.
D. Intercostal retractions
Intercostal retractions indicate increased respiratory effort and are more common in conditions like severe asthma or bronchiolitis, where the client is struggling to breathe due to lower airway obstruction. Although a pneumothorax may cause some respiratory distress, retractions are not a primary sign.
Therefore, reduced breath sounds on the right side are the most indicative finding for a right-sided pneumothorax.