A nurse is providing teaching to newly licensed nurses about cardiac tamponade. Which of the following should the nurse include when teaching about Phase Il cardiac tamponade?
Comply with compression therapy.
Monitor wounds on lower extremities.
Take antiplatelet medications as ordered.
Monitor for gradual onset of symptoms
The Correct Answer is D
A. Comply with compression therapy:
Compression therapy typically refers to the use of compression garments or devices to improve circulation and reduce swelling in the extremities, particularly in conditions such as venous insufficiency or deep vein thrombosis.
While compression therapy may be beneficial for certain circulatory disorders, it is not a standard treatment for cardiac tamponade.
Cardiac tamponade is a medical emergency characterized by the accumulation of fluid in the pericardial sac, leading to increased pressure on the heart and impaired cardiac function.
Treatment for cardiac tamponade involves prompt recognition and intervention to relieve the pressure on the heart, such as pericardiocentesis or surgical drainage of the pericardial effusion.
B. Monitor wounds on lower extremities:
Monitoring wounds on the lower extremities is essential for assessing healing, preventing complications such as infection, and promoting overall wound care.
However, monitoring wounds on the lower extremities is not directly related to the management or monitoring of cardiac tamponade.
In cardiac tamponade, the focus of monitoring is on assessing signs and symptoms of cardiac compromise, such as hypotension, tachycardia, dyspnea, and pulsus paradoxus, rather than wound care.
C. Take antiplatelet medications as ordered:
Antiplatelet medications, such as aspirin or clopidogrel, are commonly prescribed to prevent platelet aggregation and reduce the risk of thrombotic events, particularly in patients with cardiovascular disease or a history of myocardial infarction or stroke.
While antiplatelet medications may be part of the long-term management of certain cardiac conditions, they are not specific to the treatment or monitoring of cardiac tamponade.
The primary treatment for cardiac tamponade involves interventions to relieve the pressure on the heart and restore cardiac function, such as pericardiocentesis or surgical drainage of the pericardial effusion.
D. Monitor for gradual onset of symptoms:
Phase II of cardiac tamponade is characterized by a gradual onset of symptoms as the pressure within the pericardial sac increases, leading to impaired cardiac filling and decreased cardiac output.
Symptoms may include dyspnea, fatigue, orthopnea, tachycardia, and chest discomfort, which may develop gradually over time.
Early recognition of symptoms is crucial for prompt diagnosis and intervention to prevent further deterioration and improve outcomes in patients with cardiac tamponade.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Myopia: Myopia refers to nearsightedness, which is caused by refractive errors in the eye and is not associated with Meniere's disease. Myopia results in difficulty seeing distant objects clearly.
B. Vertigo: Vertigo is a hallmark symptom of Meniere's disease and is caused by an excessive accumulation of endolymph fluid in the inner ear. Vertigo presents as a sensation of spinning or dizziness, often accompanied by nausea, vomiting, and imbalance.
C. Photophobia: Photophobia refers to sensitivity to light, which can be associated with various eye conditions but is not a typical manifestation of Meniere's disease. Photophobia may occur in conditions such as migraine headaches or certain eye infections.
D. Presbycusis: Presbycusis refers to age-related hearing loss, which typically occurs gradually over time and is not directly associated with Meniere's disease. Meniere's disease is characterized by sudden episodes of vertigo, hearing loss, tinnitus, and a sensation of fullness or pressure in the ear.
Correct Answer is C
Explanation
A. Basketball, office jobs, and listening to loud music: These activities are not typically associated with an increased risk of chronic traumatic encephalopathy (CTE). While some recreational and occupational activities may involve physical or environmental risks, they are not commonly linked to the repetitive head trauma seen in CTE.
B. Swimming, working as a nurse, and painting: These activities are not commonly associated with an increased risk of CTE. Swimming is generally a low-risk activity for head injuries, while working as a nurse and painting are not typically associated with repetitive head trauma.
C. Football, military service, and physical abuse: This is the correct answer. Chronic traumatic encephalopathy (CTE) is strongly associated with repetitive head trauma, particularly in contact sports like football, as well as in military service where blast injuries and combat-related head trauma are common. Physical abuse, especially in contact sports, can also increase the risk of CTE due to repetitive blows to the head.
D. Golfing, working in construction, and horse roping: While some occupational and recreational activities may involve a risk of head injury, they are not commonly associated with the repetitive head trauma seen in CTE. Golfing, construction work, and horse roping typically do not involve the level of repetitive head impacts seen in activities like football or military service.
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