A client admitted to the hospital after being involved in a motor vehicle collision develops hypotension and severe jugular distension with a tracheal deviation. What does the nurse suspect has occurred?
1. Hemorrhage
2. Tension pneumothorax
3. Compensatory shock
4. Hypovolemic shock
2. Tension pneumothorax
Rationale:
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. Tracheal deviation and jugular vein distention are not associated with hemorrhage, compensatory shock, or hypovolemic shock.
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