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 B
Explanation
B This maneuver, called the Valsalva maneuver, can sometimes help to restore normal heart rhythm in cases of SVT. It involves blowing forcefully into a syringe or performing a similar action that increases intra-abdominal pressure, which can stimulate the vagus nerve and help to slow down the heart rate.
A Defibrillation is a treatment used for life-threatening cardiac arrhythmias, particularly ventricular fibrillation or pulseless ventricular tachycardia. It involves delivering a therapeutic dose of electrical energy to the heart with a device called a defibrillator.
C Drawing troponin levels may be appropriate if there is suspicion of myocardial infarction as the cause of chest palpitations or if there are other symptoms suggestive of acute coronary syndrome. However, in the context of SVT presenting with chest palpitations and a racing heart, the priority is to address the arrhythmia first
D Amiodarone is an antiarrhythmic medication used to treat various types of cardiac arrhythmias, including ventricular and supraventricular arrhythmias. While it can be effective in certain cases of SVT, it is not typically the first-line treatment or the immediate next step in managing SVT in the emergency department.
Correct Answer is A
Explanation
A. A heart murmur typically indicates turbulent blood flow through a heart valve. This turbulence can occur due to various reasons, such as valve stenosis (narrowing), regurgitation (leakage), or structural abnormalities of the valves. The turbulent flow produces audible sounds that can be heard with a stethoscope during cardiac auscultation.
B. A heart murmur is not caused by blood entering an inflexible chamber. Instead, it is caused by turbulent blood flow through the heart valves. The sound produced by this turbulent flow may vary depending on the underlying pathology of the valve.
C. While heart murmurs can be described based on their characteristics (such as high-pitched or low- pitched), the presence of a heart murmur does not necessarily indicate a narrow valve. Murmurs can occur due to various valve abnormalities, including stenosis (narrowing) or regurgitation (leakage). The pitch and quality of the murmur may vary depending on the underlying pathology and the location of the abnormality.
D. A heart murmur is not typically associated with inflammation around the heart. While inflammation of the heart (such as myocarditis or pericarditis) can cause symptoms and abnormal sounds, these conditions would not be described specifically as a "heart murmur."
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