# A nurse is assessing a 72-year-old client with suspected lung cancer. Which assessment finding would be most concerning and require immediate nursing intervention?

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> subject: Adult Health

## 문제

A nurse is assessing a 72-year-old client with suspected lung cancer. Which assessment finding would be most concerning and require immediate nursing intervention?

## 보기

1. Persistent cough with blood-tinged sputum for 3 weeks
2. Unintentional weight loss of 15 pounds over 2 months
3. Chest pain that worsens with deep inspiration
4. Sudden onset of severe dyspnea **✔ 정답**

**정답: 4**

## 해설

Sudden severe dyspnea with tracheal deviation indicates tension pneumothorax, a life-threatening emergency requiring immediate intervention. Other symptoms like hemoptysis, weight loss, or pleuritic pain are concerning but not immediately life-threatening.

## 심화 해설

Understanding the Priority: Airway and Breathing in Lung Cancer

When assessing a client with suspected lung cancer, the nurse must apply the clinical priority framework of airway, breathing, and circulation (ABCs). While several findings are concerning and indicative of disease progression, the one that signals a potentially life-threatening complication requiring immediate intervention is a sudden change in respiratory status.

Analysis of the Correct Answer: Sudden Onset of Severe Dyspnea

The correct answer is option 4, sudden onset of severe dyspnea. In the context of lung cancer, this is a critical red flag. A primary tumor or metastasis can erode into the visceral pleura, creating a one-way valve effect where air enters the pleural space during inspiration but cannot exit during expiration. This leads to a rapid accumulation of air, collapsing the lung and shifting the mediastinum, a condition known as tension pneumothorax. This is a life-threatening emergency because the mediastinal shift compresses the heart and great vessels, dramatically reducing cardiac output in addition to causing severe respiratory failure.

The provided evidence directly supports this urgency. One case report describes a delayed tension pneumothorax occurring after a lung procedure, which "required urgent intervention to prevent further deterioration and reduce mortality risk" [3]. This highlights that the onset of pneumothorax can be unpredictable and its progression to a tension physiology is a rapid, life-threatening event. Another report details a case of tension pneumothorax that developed after thoracentesis in a patient with an occult malignancy, underscoring the fragile nature of the diseased pleura and the potential for sudden, catastrophic air leaks [1]. While these cases are procedure-related, the underlying pathology—a lung weakened by malignancy—creates the same risk for spontaneous tension pneumothorax. The nurse must recognize that a sudden, severe increase in dyspnea is the hallmark presentation of this complication, demanding immediate notification of the rapid response team and preparation for emergency needle decompression.

Analysis of Incorrect Options

Option 1: Persistent cough with blood-tinged sputum for 3 weeks. This is a classic and concerning symptom of lung cancer, representing tumor irritation of the airway or erosion into a blood vessel. While it requires thorough investigation and management, a symptom persisting for 3 weeks is a subacute finding, not an immediate life threat. The nurse’s priority is to address acute changes in the ABCs first.

Option 2: Unintentional weight loss of 15 pounds over 2 months. This is a significant finding indicative of cancer cachexia, a systemic effect of malignancy involving metabolic dysregulation. It signals advanced disease and poor nutritional status, which can complicate treatment and recovery. However, this is a chronic finding that requires a nutritional consult and supportive care over days to weeks, not immediate intervention in the moment of assessment.

Option 3: Chest pain that worsens with deep inspiration. This description fits pleuritic chest pain, which is highly suggestive of pleural involvement by the tumor. The pain is caused by inflammation of the parietal pleura, which is innervated by somatic nerves. While distressing and requiring prompt analgesic management, it does not independently signal a life-threatening, acute physiological derangement like a tension pneumothorax does. A severe aspiration event, as described in one source, can lead to a rapid deterioration with hypoxemia , but the key differentiator in the correct answer is the word "sudden" combined with "severe dyspnea," which points more directly to an acute air or fluid accumulation compromising ventilation.References (research sources)

- [1]Reassessing Discordant Exudative Pleural Effusion in Heart Failure: A Rare Case of Occult Malignancy Uncovered by Post-Thoracentesis Tension Pneumothorax.Research articleOrdookhanian C, Amidon RF, Hanna S, Tabibian B. (2026) · DOI: 10.1002/ccr3.72608

- [3]Delayed Tension Pneumothorax After Microwave Ablation of Lung Metastasis.Research articleWang Y, Jiang Y, Wang L, Jiang X. (2025) · DOI: 10.1093/icvts/ivaf208

## 임상 시나리오

Tension Pneumothorax RecognitionLung Cancer Emergency Management
In a patient with lung cancer, sudden onset of severe dyspnea is a red flag for tension pneumothorax. A tumor can erode into the pleura, creating a one-way valve that traps air.

This trapped air collapses the lung and causes a mediastinal shift, compressing the heart and great vessels. This leads to obstructive shock and cardiovascular collapse if not immediately decompressed.

CautionDo not wait for imaging confirmation if the patient shows tracheal deviation, distended neck veins, and absent breath sounds. Immediate needle decompression at the 2nd intercostal space, midclavicular line is required, followed by chest tube insertion.

## 핵심 개념

- **Tension Pneumothorax** — A life-threatening condition where air accumulates in the pleural space under pressure, collapsing the lung and shifting the mediastinum, which compresses the heart and great vessels.
- **ABC Priority Framework** — A clinical triage model prioritizing Airway, Breathing, and Circulation; sudden breathing changes take precedence over chronic or stable findings.
- **Mediastinal Shift** — Deviation of the trachea and heart from the midline caused by pressure buildup in one side of the chest, a hallmark sign of tension pneumothorax.

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