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A nurse is working in an emergency department is caring for a client following an acute chest trama. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax?

(a) The client is experiencing sudden onset chest pain and shortness of breath.

(b) The client is experiencing a decrease in blood pressure and an increase in heart rate.

(c) The client is experiencing tracheal deviation away from the side of the chest trauma.

(d) The client is experiencing decreased breath sounds on the affected side of the chest.

User AliKarimi
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1 Answer

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Final answer:

The definitive sign of tension pneumothorax among the provided options is tracheal deviation away from the side of the chest trauma (c), along with symptoms like sudden onset chest pain, shortness of breath, and decreased breath sounds on the affected side.

Step-by-step explanation:

The client experiencing a tension pneumothorax would most likely present with several clinical findings, but the definitive one among the options provided is (c) tracheal deviation away from the side of the chest trauma. This occurs because the pressure in the pleural space is increasing due to trapped air from the lung injury, and as a result, the trachea is pushed to the opposite side. Along with tracheal deviation, a combination of sudden onset chest pain and shortness of breath (a), and decreased breath sounds on the affected side of the chest (d) is often present. However, the worrisome sign that indicates a more severe and life-threatening issue like tension pneumothorax would certainly be the deviation of the trachea. Also of note are decreases in blood pressure and increases in heart rate (b), which would be expected as the condition deteriorates, but these symptoms are not as specific to tension pneumothorax as tracheal deviation. It is critical for the nurse to recognize these signs promptly to initiate the necessary emergency interventions to decompress the pleural space and stabilize the client.

User Karthik T
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