A client recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred?
A) Hemorrhage
B) Compensatory shock
C) Hypovolemic shock
D) Tension pneumothorax
Answer: D
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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