Question

A client is brought in with a gunshot wound to the chest. The nurse assesses further for tension pneumothorax. What signs and symptoms of tension pneumothorax can the nurse expect to find?

a) Bradycardia and hypotension
b) Decreased respiratory rate
c) Tracheal deviation away from the affected side
d) Diminished breath sounds on the unaffected side

Answer 1

The signs and symptoms of tension pneumothorax that the nurse can expect to find are tracheal deviation away from the affected side, diminished breath sounds on the unaffected side, and increased respiratory rate (Options C and D).

Step-by-step explanation:

When assessing a client for tension pneumothorax, the nurse should look for signs and symptoms that indicate a buildup of air in the pleural space, causing the lung to collapse and putting pressure on the heart and other structures.

One of the main signs is tracheal deviation away from the affected side. This occurs because the lung on the affected side is deflated, causing the trachea to shift towards the unaffected side.

The nurse may also observe diminished breath sounds on the unaffected side, as air is trapped in the affected side and does not flow to the other lung.

Additionally, the nurse should monitor for increased respiratory rate as the body compensates for the decreased oxygen levels.

Hence, the correct answers are Options C and D.