A patient is admitted to the hospital with injuries from a motor vehicle collision. During the nurse's initial assessment, the patient develops hypotension and severe jugular distention with a tracheal deviation
The nurse should act quickly to treat which probable condition? 1. Tension pneumothorax
2. Hemorrhage
3. Compensatory shock
4. Hypovolemic shock
1
Rationale 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.
Rationale 2: The patient would not have jugular vein distention with hemorrhage.
Rationale 3: The patient would not have jugular vein distention or tracheal deviation in the presence of compensatory shock.
Rationale 4: Hypovolemic shock is not characterized by jugular vein distention and tracheal deviation.
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