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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to inquire about an allergy to iodine in a patient who has undergone an angiogram, it’s not typically the priority for assessing and documenting for this patient after the procedure. An allergy to iodine would be more relevant before the procedure, as iodine-based contrast dye is often used during an angiogram.
Choice B rationale
Checking peripheral pulses in the affected leg is typically a priority when caring for a patient who has undergone an angiogram. This is because the procedure involves inserting a catheter into a blood vessel in the leg. Checking the peripheral pulses can help assess for potential complications such as a blood clot or decreased blood flow to the leg.
Choice C rationale
Monitoring for decreased blood pressure is important in a patient who has undergone an angiogram, but it’s not typically the priority for assessing and documenting for this patient after the procedure. While changes in blood pressure can occur after any medical procedure, other assessments such as checking peripheral pulses in the affected leg are typically more directly related to potential complications of an angiogram.
Choice D rationale
Tracking fluid intake is an important part of overall patient care, but it’s not typically the priority for assessing and documenting for a patient who has undergone an angiogram. Other assessments such as checking peripheral pulses in the affected leg are typically more directly related to potential complications of an angiogram.
Correct Answer is D
Explanation
Choice A rationale
Cramping of the toes is not typically associated with a positive Homans sign. Homans sign is a test used to check for deep vein thrombosis (DVT), a blood clot in a deep vein of the leg. While cramping can occur with DVT, it is not specific to this condition and can occur with many other conditions.
Choice B rationale
Blanching of the sole is not associated with a positive Homans sign. Blanching, or whitening of the skin, can occur with various conditions, but it is not a typical sign of DVT45.
Choice C rationale
Resisting dorsiflexion is not a typical response indicating a positive Homans sign. While pain or resistance during dorsiflexion of the foot can occur with various conditions, it is not a specific sign of DVT45.
Choice D rationale
Pain in the calf area during dorsiflexion of the foot (Homans sign) can indicate a positive sign for DVT. However, it’s important to note that Homans sign is not a reliable or definitive test for DVT. Other diagnostic tests, such as ultrasound, are needed to confirm the diagnosis.
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