2. During the physical assessment of a client diagnosed with a right tension pneumothorax, a nurse would expect to find:
Select all that apply.
2. During the physical assessment of a client diagnosed with a right tension pneumothorax, a nurse would expect to find:
Select all that apply.
. Tracheal shift to the left.
. Tracheal shift to the right.
. Decreased breath sounds on the right side.
. Subcutaneous emphysema on the left chest.
. Increased breath sounds on the left side.
. Point of Maximum Impulse (PMI) shifted further to the left of midline.
Test-Taking Tip
Look for key words in the options and ask if those findings would occur if the pressure were on the right side.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
. . .
Answer 1 is correct because, during a tension pneumothorax, thoracic structures are pushed toward the opposite side. Answer 2 is incorrect because thoracic structures are pushed toward the opposite side of the problem. Since Answer 1 is correct, this answer is wrong. Answer 3 is correct because pneumothorax causes partial or total collapse of the lung; therefore, breath sounds would be diminished or absent. Answer 4 is incorrect because, if present, the subcutaneous emphysema would be in the affected side (i.e., right side). Answer 5 is incorrect because the pressure on the nonaffected side might result in a decrease, or no change, in breath sounds. Answer 6 is correct because thoracic structures, including the heart, would shift to the left.