When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?

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, which is a grating sound caused by the inflammation of the pleural surfaces during respiration, is not typically associated with cardiac tamponade. It is more commonly associated with conditions affecting the lungs, such as pneumonia or pleurisy.
Choice B rationale
Distended neck veins are a classic sign of cardiac tamponade. This occurs due to increased pressure in the right atrium as a result of the impaired filling of the ventricles. This is a critical sign that should be reported immediately.
Choice C rationale
Widening pulse pressure (an increase in the difference between systolic and diastolic blood pressure) is not typically associated with cardiac tamponade. In fact, cardiac tamponade more commonly presents with a narrowed pulse pressure.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of cardiac tamponade. More commonly, tachycardia, or a fast heart rate, is observed in response to decreased cardiac output.

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Correct Answer is D

Explanation

Choice A rationale
Encouraging exercise to increase heart rate in a patient with myocardial ischemia could potentially worsen the condition. Exercise increases the demand for oxygen in the heart, which may not be met due to the reduced blood flow in ischemia, potentially leading to further damage.
Choice B rationale
Administering a diuretic to decrease volume is not the most beneficial intervention for a patient with myocardial ischemia. While diuretics can reduce the workload of the heart by decreasing blood volume, they do not directly address the issue of reduced blood flow to the heart muscle that characterizes ischemia.
Choice C rationale
Giving an antibiotic to decrease infection is not relevant in this context. Myocardial ischemia is not caused by an infection, but by a reduction in blood flow to the heart muscle, often due to a blockage in one or more of the coronary arteries.
Choice D rationale
Applying oxygen to increase myocardial oxygen supply is the most beneficial intervention for a patient with myocardial ischemia. Oxygen therapy can help to meet the oxygen demand of the heart muscle when blood flow is reduced, alleviating symptoms and preventing further damage.

A. The patient smokes cigarettes. B. The patient eats bananas twice a day. C. The patient wears mittens outside. D. The patient takes calcium channel blockers.

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.

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When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 49-year-old male presents with chest pain. An EKG reveals ST elevation, and he is diagnosed with myocardial ischemia. Which of the following interventions would be most beneficial for this patient?

Correct Answer is D

Explanation

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

Correct Answer is A

Explanation

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