Difficulty: Medium
Average Score: 78%
Simulated
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
Correct answer
C
Rationale
A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.