A nurse is caring for a client in a critical care unit who is 4 hours post-operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?
New systolic murmur
Diminished breath sounds
Diminished heart sounds
Increased blood pressure
The Correct Answer is C
A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cardiac enzymes do not diagnose pulmonary congestion. Pulmonary congestion is typically assessed using imaging, such as a chest X-ray or echocardiography.
B. Cardiac enzyme tests do not assess heart structure or valve mobility. An echocardiogram or cardiac MRI is used for that purpose.
C. Cardiac enzymes, such as troponins and creatine kinase-MB (CK-MB), indicate the extent of myocardial damage and are essential for diagnosing and managing acute myocardial infarction.
D. Cardiac enzymes confirm myocardial injury but do not pinpoint the exact location of the infarction. The location is determined using ECG findings and imaging studies.
Correct Answer is C
Explanation
A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.
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.
