A patient is admitted to the hospital with injuries from a motor vehicle crash. During the nurse's initial assessment, the patient develops hypotension and severe jugular distension with a tracheal deviation
What should the nurse suspect is occurring in this patient?
1. tension pneumothorax
2. hemorrhage
3. compensatory shock
4. hypovolemic shock
Correct Answer: 1
A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung. The patient would not have jugular vein distention with a hemorrhage, compensatory shock, or hypovolemic shock.
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