A client is brought in with a gunshot wound to the chest. The nurse assesses for tension pneumothorax. What signs and symptoms of tension pneumothorax can the nurse expect to find?
A) deviated trachea
B) high blood pressure
C) wheezes in all lung fields
D) audible sucking sounds on inspiration
A
Explanation:
A)
As air enters the pleural space, it is unable to escape and accumulates, causing collapse of the lung on the affected side and shifting of the heart, trachea, and esophagus to the unaffected side.
Analysis
Assessment
Physiological Integrity: Physiological Adaptation
B)
As air enters the pleural space, it is unable to escape and accumulates, causing collapse of the lung on the affected side and shifting of the heart, trachea, and esophagus to the unaffected side.
Analysis
Assessment
Physiological Integrity: Physiological Adaptation
C)
As air enters the pleural space, it is unable to escape and accumulates, causing collapse of the lung on the affected side and shifting of the heart, trachea, and esophagus to the unaffected side.
Analysis
Assessment
Physiological Integrity: Physiological Adaptation
D)
As air enters the pleural space, it is unable to escape and accumulates, causing collapse of the lung on the affected side and shifting of the heart, trachea, and esophagus to the unaffected side.
Analysis
Assessment
Physiological Integrity: Physiological Adaptation
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