A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?

Pleural friction rub

Distended neck veins

Widening pulse pressure

Bradycardia .

Answer and Explanation

The Correct Answer is B

Choice A rationale
A pleural friction rub is an audible raspy breathing sound, a medical sign present in some patients with pleurisy and other conditions affecting the chest cavity. It is not a typical symptom of cardiac tamponade.
Choice B rationale
Distended neck veins are a result of the collapsed blood vessels that should return blood to the heart. This is a common symptom of cardiac tamponade.
Choice C rationale
Widening pulse pressure occurs with valvular heart disease, not typically with cardiac tamponade.
Choice D rationale
Bradycardia, or a slower-than-normal heart rate, is not typically associated with cardiac tamponade.

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Correct Answer is A

Explanation

Choice A rationale
Smoking cigarettes can exacerbate the symptoms of Raynaud’s disease by causing further constriction of the blood vessels. Therefore, a patient who continues to smoke cigarettes may need further education about the management of Raynaud’s disease.
Choice B rationale
Eating bananas twice a day is not typically a concern for patients with Raynaud’s disease.
Choice C rationale
Wearing mittens outside, especially in cold weather, is a recommended strategy for managing Raynaud’s disease. It can help to prevent episodes of Raynaud’s by keeping the hands warm and reducing exposure to cold temperatures.
Choice D rationale
Taking calcium channel blockers is a common treatment for Raynaud’s disease. These medications help to relax and open up the small blood vessels in the hands and feet, reducing the severity and frequency of Raynaud’s episodes.

A. On the left side at the midclavicular line, fifth intercostal space. B. Directly over the heart on the sternum. C. On the right side at the midclavicular line, fourth intercostal space. D. At the midaxillary level on the left side.

Correct Answer is A

Explanation

Choice A rationale
The apical pulse, also known as the point of maximal impulse (PMI), is located at the fifth intercostal space at the left midclavicular line. This is the location where the heartbeat is strongest and is the standard location for assessing the apical heart rate.
Choice B rationale
Placing the stethoscope directly over the heart on the sternum is not the standard method for assessing the apical heart rate. While the sternum is close to the heart, it is not the location where the heartbeat is strongest or most easily heard.
Choice C rationale
The right side at the midclavicular line, fourth intercostal space, is not the standard location for assessing the apical heart rate. The heart is located more towards the left side of the chest, and the apical pulse is typically not as easily heard on the right side.
Choice D rationale
The midaxillary line on the left side is not the standard location for assessing the apical heart rate. While this location is on the left side of the chest, it is not where the heartbeat is strongest or most easily heard.

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A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?

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Naxlex Comprehensive Predictor Exams

Which of the following findings in a patient with Raynaud’s disease would indicate a need for further teaching?

Correct Answer is A

Explanation

In the context of interprofessional care of the client and family, where should a nurse position the stethoscope on the chest to assess a client’s apical heart rate?

Correct Answer is A

Explanation

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