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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Hypovolemia, or low blood volume, can lead to decreased venous return to the heart and reduced filling pressures. Consequently, CVP may decrease in hypovolemic states. Low CVP may indicate inadequate preload and reduced cardiac output, which are characteristic of hypovolemia.

A. Left ventricular failure typically results in elevated filling pressures rather than low CVP. In left ventricular failure, blood backs up into the pulmonary circulation, leading to increased pulmonary venous pressure and potentially elevated pulmonary capillary wedge pressure (PCWP), which is a surrogate marker for left atrial pressure. This elevated pressure is reflected in the CVP as well, resulting in increased CVP rather than low CVP.

B. Fluid overload typically results in elevated filling pressures and increased CVP rather than low CVP. Excess fluid volume increases venous return to the heart, leading to increased pressure within the central veins and elevated CVP.

D. Intracardiac shunts may cause alterations in cardiac pressures, but they typically do not result in consistently low CVP. Depending on the type and severity of the shunt, the direction and magnitude of pressure changes may vary. However, in the absence of other pathophysiological factors, intracardiac shunts are less likely to cause consistently low CVP.

A. Re-zero the monitoring equipment. B. Check the left hand for pallor. C. Fast flush the arterial line. D. Assess for dysrhythmias

Correct Answer is B

Explanation

B. Checking the left hand for pallor can help assess peripheral perfusion and determine if there is adequate blood flow distal to the arterial line insertion site. Pallor in the left hand could indicate decreased perfusion, which may contribute to the low-pressure alarm.

A. Re-zeroing the monitoring equipment may be necessary to ensure accurate pressure readings. However, it should not be the first action taken when the low-pressure alarm sounds. Before re-zeroing, the nurse should assess the patient's condition to ensure there are no immediate issues affecting arterial pressure.

C. Fast flushing the arterial line is not typically the first action to take when the low-pressure alarm sounds. Fast flushing may increase the risk of dislodging the catheter or causing air embolism if there is a problem with the line.

D. Assessing for dysrhythmias should be part of the overall assessment but may not be the first action taken in response to the alarm.

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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?

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Correct Answer is C

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Correct Answer is B

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