In a client with chest trauma, the nurse needs to evaluate mediastinal position.
This can best be done by:
A . Auscultating bilateral breath sounds
B . Palpating for presence of crepitus
C . Palpating for trachial deviation
D . Auscultating heart sounds
Answer: C
Explanation:
(A) No change in the breath sounds occurs as a direct result of the mediastinal shift.
(B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift.
(C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the heart’spoint of maximum impulse.
(D) No change in the heart sounds occurs as a result of the mediastinal shift.