Which symptom should a nurse assess for in a patient suspected of having tension pneumothorax?

In a patient suspected of having a tension pneumothorax, assessing for the absence of breath sounds on one side is critical. This symptom indicates that air is trapped in the pleural space, which prevents normal lung expansion on the affected side and interferes with airflow. The accumulation of air under pressure can lead to significant respiratory distress, and the lack of breath sounds is a direct result of the lung being compressed or collapsed.

This assessment is vital in the clinical setting because it helps differentiate tension pneumothorax from other conditions that may present similarly. Detecting unilateral breath sounds can prompt immediate intervention, as tension pneumothorax is a life-threatening emergency that requires rapid decompression to relieve pressure and restore respiratory function.

Other symptoms, such as decreased blood pressure or bradycardia, may relate to the overall hemodynamic instability caused by a tension pneumothorax but are not specific indicators for assessment in this scenario. Similarly, fluid retention does not pertain directly to the condition and may indicate other issues unrelated to pneumothorax. Thus, the focus on the absence of breath sounds demonstrates a clear understanding of the pathophysiology and urgency associated with tension pneumothorax.