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 C
Explanation
Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice B rationale
Cardioverting the client with a biphasic defibrillator is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice C rationale
The first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern is to assess the patient’s airway, breathing, and circulation.
Choice D rationale
Administering an amiodarone bolus followed by a drip is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Correct Answer is A
Explanation
Choice A rationale
Skin hyperpigmentation is a common symptom of chronic venous insufficiency. This happens because blood pools in the veins and can leak into the surrounding tissue, causing a change in skin color.
Choice B rationale
Gangrene is not a typical symptom of chronic venous insufficiency. Gangrene is a serious condition that occurs when tissue dies due to a lack of blood flow.
Choice C rationale
Edema, or swelling, is a common symptom of chronic venous insufficiency, but it typically occurs in the lower legs and ankles, not above the knee.
Choice D rationale
Deep vein thrombus formation is not a typical symptom of chronic venous insufficiency. However, a history of deep vein thrombosis can increase the risk of developing chronic venous insufficiency.
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