A nurse is caring for a client in the emergency department (ED).

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

C Atrial fibrillation (AF) is characterized by rapid, irregular electrical activity in the atria, leading to an irregularly irregular ventricular response. AF often results in palpitations, fatigue, and dizziness due to the irregular heart rhythm and inefficient cardiac output. A significant pulse deficit may also be present due to the irregularity of the ventricular response compared to the atrial activity. Given the sudden onset of irregular palpitations, fatigue, dizziness, and a significant pulse deficit, atrial fibrillation is a likely dysrhythmia in this scenario.

A First-degree AV block is characterized by a prolonged PR interval on the electrocardiogram (ECG), indicating delayed conduction between the atria and ventricles. While it can indicate conduction system abnormalities, it typically does not result in rapid or irregular palpitations, fatigue, or dizziness.

Therefore, it is less likely to be the cause of the client's symptoms.

B Sinus tachycardia is characterized by a rapid heart rate originating from the sinus node, typically with a regular rhythm. While sinus tachycardia can cause palpitations and fatigue, it is less likely to result in an irregular heart rate with a significant pulse deficit. Therefore, it is less likely to be the cause of the client's symptoms.

D Sinus bradycardia is characterized by a slow heart rate originating from the sinus node. While sinus bradycardia can cause fatigue and dizziness, it typically does not result in a rapid or irregular heart rate. Therefore, it is less likely to be the cause of the client's symptoms.

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.