The nurse is assessing a patient following a cardiac catheterization.
On assessment, they note muffled heart sounds, jugular vein distention, and hypotension.
The nurse knows these are signs of what?
Cardiac tamponade
Artery dissection
These are normal findings following stent placement
Myocardial Infarction
The Correct Answer is A
Cardiac tamponade is a life-threatening condition that occurs when fluid accumulates in the pericardial sac, the thin, doublelayered membrane that surrounds the heart. This fluid buildup compresses the heart, preventing it from filling properly and pumping blood effectively.
The classic triad of symptoms of cardiac tamponade is muffled heart sounds, jugular vein distention (JVD), and hypotension.
Muffled heart sounds occur because the fluid in the pericardial sac dampens the sound of the heart's valves closing. JVD occurs because the fluid in the pericardial sac compresses the superior vena cava, which is a large vein that carries blood from the upper body back to the heart. Hypotension occurs because the compressed heart is unable to pump blood effectively.
Other signs and symptoms of cardiac tamponade may include:
Tachycardia (rapid heart rate)
Dyspnea (shortness of breath)
Chest pain
Pulsus paradoxus (a drop in blood pressure during inspiration)
Anxiety or restlessness
Altered mental status
Cardiac tamponade is a medical emergency that requires immediate treatment. The goal of treatment is to relieve the pressure on the heart by removing the fluid from the pericardial sac. This is typically done through a procedure called pericardiocentesis, which involves inserting a needle into the pericardial sac and draining the fluid.
Choice B rationale:
Artery dissection is a condition that occurs when the inner layer of an artery tears, allowing blood to flow between the layers of the artery wall. This can lead to a number of complications, including aneurysm formation, rupture, and ischemia (lack of blood flow) to the organs and tissues supplied by the affected artery.
The signs and symptoms of artery dissection vary depending on the location of the dissection. Common symptoms include sudden, severe pain; weakness or numbness; and a difference in blood pressure between the arms or legs.
Artery dissection is a serious condition that requires prompt medical attention. Treatment options may include medication, surgery, or a combination of both.
Choice C rationale:
It is not normal to have muffled heart sounds, JVD, and hypotension following stent placement. These are signs of a serious complication, such as cardiac tamponade or artery dissection.
Choice D rationale:
Myocardial infarction (MI), also known as a heart attack, occurs when blood flow to a portion of the heart is blocked, causing damage to the heart muscle. The classic symptom of an MI is chest pain, but other symptoms may include shortness of breath, nausea, vomiting, sweating, and lightheadedness.
The signs and symptoms of cardiac tamponade and MI can overlap, but there are some key differences. For example, chest pain is more common in MI, while JVD is more common in cardiac tamponade.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Bradycardia refers to a slow heart rate, typically defined as less than 60 beats per minute.
While some ICDs can provide pacing for bradycardia, this is not their primary purpose.
Their primary goal is to prevent sudden cardiac death from life-threatening arrhythmias.
Therefore, Choice A is not the best response.
Choice B rationale:
Atrial fibrillation (AFib) is a common heart rhythm disorder characterized by rapid and irregular beating of the atria.
While ICDs can sometimes be used in patients with AFib, this is not their primary indication.
AFib is typically managed with medications to control heart rate and rhythm, or with ablation procedures to disrupt the abnormal electrical pathways.
Therefore, Choice B is not the best response.
Choice C rationale:
Ventricular fibrillation (VF) and ventricular tachycardia (VT) are life-threatening arrhythmias that originate in the ventricles of the heart.
VF is characterized by chaotic, disorganized electrical activity in the ventricles, leading to ineffective pumping and cardiac arrest.
VT is a very fast heart rhythm that can degenerate into VF.
ICDs are specifically designed to detect and treat VF and VT.
They do this by delivering electrical shocks to the heart, which can restore a normal rhythm.
Therefore, Choice C is the best response.
Choice D rationale:
While ICDs can deliver shocks during a heart attack, this is not their primary purpose.
Heart attacks are caused by a blockage of blood flow to the heart muscle, and they are typically treated with medications, such as aspirin, nitroglycerin, and clot-busting drugs.
ICDs are primarily used to prevent sudden cardiac death from life-threatening arrhythmias, not to treat heart attacks themselves.
Correct Answer is A
Explanation
Choice A rationale:
Venous thromboembolism (VTE) is a blood clot that forms in a vein, usually in the legs. It can be a serious condition, as the clot can break loose and travel to the lungs, causing a pulmonary embolism (PE).
Crossing the legs at the knees can impede blood flow in the veins of the legs, increasing the risk of VTE. This is because it compresses the veins, slowing the flow of blood and making it more likely for clots to form.
The patient's statement that they will make sure not to cross their legs when resting in bed demonstrates that they understand this important risk factor for VTE and are taking steps to prevent it.
Choice B rationale:
While keeping pillows under the knees can help to improve circulation, it is not a specific measure to prevent VTE. It is more important to avoid crossing the legs and to engage in regular movement and activity to promote blood flow.
Choice C rationale:
Compression stockings can help to reduce the risk of VTE by compressing the veins in the legs and promoting blood flow. However, they should be worn as instructed by a healthcare professional, and not only if the patient experiences pain in their calves. Pain in the calves can be a symptom of VTE, so it is important to seek medical attention if it occurs.
Choice D rationale:
Bed rest is actually a risk factor for VTE, as it can lead to decreased blood flow in the legs. It is important to get up and move around as soon as possible after surgery, even if it is just for short periods of time. This will help to promote blood flow and reduce the risk of VTE.
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