A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Bradycardia.
Muffled heart sounds
Flattened neck veins.
Sudden lethargy.
The Correct Answer is B
B. Muffled heart sounds, often described as distant or indistinct, are classic findings in cardiac tamponade. The accumulation of fluid in the pericardial sac dampens the transmission of sound from the heart to the chest wall, resulting in muffled heart sounds on auscultation. This finding is known as Beck's triad, which also includes hypotension and jugular venous distention.
A. Bradycardia is not a typical finding in cardiac tamponade. In fact, tachycardia is more commonly observed due to the compensatory response to decreased cardiac output and decreased stroke volume. The sympathetic nervous system is activated, leading to an increase in heart rate as a compensatory mechanism to maintain cardiac output.
C. Flattened neck veins are not consistent with cardiac tamponade. In cardiac tamponade, jugular venous distention (JVD) is typically observed due to increased venous pressure resulting from impaired right ventricular filling. The presence of JVD is an important clinical finding in cardiac tamponade and can help differentiate it from other causes of shock.
D. Sudden lethargy can occur in various medical emergencies, including cardiac tamponade, but it is not a specific or diagnostic finding for this condition. In cardiac tamponade, symptoms may include dyspnea, chest pain, hypotension, and signs of decreased cardiac output such as cool extremities and altered mental status. However, sudden lethargy alone may not be specific enough to confirm cardiac tamponade.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Hypotension may result from decreased cardiac output due to hypoxemia and acidosis or as a compensatory response to hypoxia-induced vasodilation. Therefore, monitoring for hypotension is important in ARF.
C. Hypoxemia can impair cerebral perfusion and neuronal function, leading to alterations in mental status ranging from confusion to coma. Decreased level of consciousness is a concerning sign of inadequate oxygenation and should be closely monitored in patients with ARF.
D. Dyspnea, or difficulty breathing, is a hallmark symptom of respiratory failure. In ARF, the respiratory system's inability to adequately oxygenate or ventilate leads to increased work of breathing and feelings of breathlessness. Patients with ARF often experience severe dyspnea as they struggle to maintain adequate gas exchange.
E. Headache is not typically considered a primary manifestation of ARF. However, it may occur as a secondary symptom due to factors such as hypoxemia, hypercapnia, or acidosis. Patients with ARF may experience headache as a result of cerebral vasodilation in response to hypoxia or as a symptom of underlying conditions contributing to respiratory failure.
B. Nausea is not a typical manifestation of ARF itself. However, it may occur as a secondary symptom due to factors such as hypoxia, acidosis, or medications administered for the management of ARF. While nausea may be present, it is not a direct result of respiratory failure.
Correct Answer is B
Explanation
B. Cheyne-Stokes respirations involve a cyclical pattern of breathing characterized by gradual increase and decrease in the depth and rate of respirations, with periods of hyperventilation alternating with periods of apnea. It is commonly seen in patients with neurological disorders, heart failure, or drug overdose.
A. Apneustic respirations are characterized by prolonged inspiratory gasps followed by a brief pause and insufficient expiration. This pattern is often associated with damage to the pons in the brainstem.
C. Stridor is a high-pitched, noisy respiratory sound caused by turbulent airflow through partially obstructed airways. It is typically heard during inspiration and is often associated with upper airway obstruction, such as in cases of croup or epiglottitis.
D. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in patients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.
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