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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Rheumatoid arthritis is an autoimmune disease that primarily affects the joints. While it can increase the risk of cardiovascular disease due to systemic inflammation, it is not typically considered a direct cause of secondary hypertension.
Choice B rationale
Coarctation of the aorta, a congenital condition characterized by a narrowing of the aorta, can cause secondary hypertension. This is because the narrowing can increase resistance to blood flow, leading to increased pressure.
Choice C rationale
Increased intracranial pressure (ICP) can cause secondary hypertension as part of Cushing’s reflex, a physiological response to protect the brain from damage. This reflex can lead to an increase in systemic blood pressure in an attempt to maintain cerebral perfusion.
Choice D rationale
Renal disease is a common cause of secondary hypertension. The kidneys play a crucial role in regulating blood pressure, and damage to the kidneys can lead to hypertension.
Choice E rationale
Colon cancer is not typically associated with secondary hypertension. While some cancers can produce substances that increase blood pressure, colon cancer is not commonly associated with this phenomenon.
Correct Answer is D
Explanation
Choice A rationale
Exercise electrocardiography, also known as a stress test, is not typically the first-line emergent procedure for a patient with an acute myocardial infarction (AMI). This test is often used to diagnose coronary artery disease, but it is not typically used to treat an AMI5.
Choice B rationale
A computed tomography (CT) scan of the chest with contrast could be used to visualize the heart and surrounding structures, but it is not typically the first-line emergent procedure for a patient with an AMI5.
Choice C rationale
An echocardiogram could be used to visualize the heart’s structure and function, but it is not typically the first-line emergent procedure for a patient with an AMI5.
Choice D rationale
Percutaneous coronary intervention (PCI) is the correct answer. This procedure is often used as an emergent treatment for an AMI. It involves using a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup.
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