A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?

Rationale:

• Elevated blood glucose: A random glucose level of 220 mg/dL is mildly elevated and can be expected during acute illness or stress, especially in clients with diabetes. It should be monitored but does not require immediate intervention in this cardiac context.
• Elevated heart rate: A heart rate of 116/min reflects tachycardia, which may result from pain, anxiety, or reduced cardiac output. While it is an important finding, it is secondary to more urgent issues like chest pain or myocardial injury.
• Epigastric discomfort: Epigastric discomfort alone is not an emergency finding and can occur in non-cardiac conditions such as GERD or peptic ulcer disease. While it may signal atypical angina, it lacks the specificity or urgency of active chest pain.
• Chest pain: Chest pain is a classic symptom of myocardial ischemia and warrants immediate intervention. The nurse should apply oxygen, initiate cardiac monitoring, assess pain characteristics, establish IV access, and prepare to administer nitroglycerin or aspirin per protocol.
• Elevated troponin: A troponin level of 10.15 ng/mL confirms myocardial injury and supports the diagnosis of myocardial infarction. The nurse should report this result immediately, anticipate further cardiac workup, continue ECG and vital monitoring, and prepare the client for possible transfer to a higher level of care.
• Elevated blood pressure: A BP of 158/92 mm Hg is elevated but not critical in this context. It is likely a response to pain or anxiety and can be managed after more urgent issues, such as ischemia or infarction, have been addressed.

Rationale:
A. First-degree heart block: This rhythm shows a prolonged PR interval but maintains regular P waves before every QRS complex and a consistent rhythm. The presence of P waves and regularity rule out this option.

B. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm and absent or indistinct P waves due to disorganized atrial electrical activity. A heart rate of 98/min with no clear P waves fits the criteria for this dysrhythmia.

C. Complete heart block: Complete (third-degree) heart block features a complete dissociation between atrial and ventricular activity, with P waves and QRS complexes occurring independently. It typically presents with a bradycardic rhythm, not near 98/min.

D. Ventricular tachycardia: Ventricular tachycardia presents with a rapid, regular rhythm and wide QRS complexes. It usually lacks P waves but is typically much faster than 98/min, often ranging from 140 to 200 beats/min.