A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?
Muffled heart sounds
Decreased jugular vein distention
Widening pulse pressure
Coarse lung sounds
The Correct Answer is A
A. Muffled heart sounds: Muffled or distant heart sounds occur due to accumulation of fluid in the pericardial sac, which dampens the transmission of heart sounds. This is an early and classic manifestation of cardiac tamponade, reflecting impaired ventricular filling and reduced stroke volume. Prompt recognition is critical to prevent hemodynamic compromise.
B. Decreased jugular vein distention: Cardiac tamponade typically causes increased jugular vein distention due to impaired right atrial filling and elevated central venous pressure. A decrease in jugular venous distention would be inconsistent with this condition.
C. Widening pulse pressure: Cardiac tamponade usually produces a narrowing pulse pressure due to reduced stroke volume and systolic pressure, rather than widening. A widened pulse pressure is more characteristic of conditions like aortic regurgitation.
D. Coarse lung sounds: Coarse lung sounds are associated with pulmonary edema or fluid in the alveoli, not with pericardial tamponade. Lung sounds are often normal in early tamponade unless concurrent pulmonary complications are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Candidiasis: Candidiasis is a common fungal infection that is not nationally notifiable. While it may require treatment, it does not need to be reported to the state health department for public health surveillance.
B. Chlamydia: Chlamydia is a nationally notifiable sexually transmitted infection. Reporting to the state health department is required to monitor prevalence, track outbreaks, and implement public health interventions to reduce transmission.
C. Herpes simplex virus: Genital herpes infections are not generally reportable to public health authorities in most states, though some jurisdictions may require reporting under specific circumstances. It is not considered nationally notifiable in the same way as chlamydia.
D. Human papillomavirus: HPV infection is highly prevalent and usually asymptomatic, and it is not a nationally notifiable disease. Public health efforts focus on vaccination and screening rather than mandatory reporting.
Correct Answer is ["A","B"]
Explanation
A. Food stamps: Supplemental Nutrition Assistance Program (SNAP), commonly called food stamps, provides financial assistance for purchasing nutritious food. For a client below the poverty level, this resource helps ensure adequate nutrition, which is essential for recovery during home IV therapy.
B. Medicaid: Medicaid offers health coverage for low-income individuals, including coverage for home health services and necessary medical equipment. Enrolling the client in Medicaid can facilitate access to home IV therapy and reduce out-of-pocket expenses.
C. Respite care: Respite care provides temporary relief to caregivers but is not directly relevant to a young adult client managing home IV therapy independently. While useful in certain situations, it is not a primary resource for financial or medical support in this case.
D. Medicare Part A: Medicare primarily covers hospital and skilled nursing facility care for adults over 65 or with certain disabilities. A young adult below the poverty level is unlikely to qualify, making this an inappropriate recommendation for home IV therapy coverage.
E. Adult day care: Adult day care services are designed for older adults requiring supervision or social interaction. This service is not applicable for a young adult client requiring home IV therapy and does not address financial or medical support needs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.