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?
Fever
Atrial fibrillation
Paradoxical pulse
Pericardial friction rub
The Correct Answer is C
Rationale:
A. Fever: While fever may occur in pericarditis due to inflammation or infection, it is not specific to cardiac tamponade. It reflects a systemic inflammatory response rather than a mechanical complication like fluid accumulation compressing the heart.
B. Atrial fibrillation: Atrial fibrillation may develop in some cardiac conditions, including pericarditis, but it is not a hallmark feature of cardiac tamponade. It does not directly reflect the hemodynamic compromise seen with tamponade.
C. Paradoxical pulse: Paradoxical pulse (pulsus paradoxus) is a key sign of cardiac tamponade. It refers to an exaggerated decrease in systolic blood pressure during inspiration, caused by restricted ventricular filling from fluid accumulation in the pericardial sac, leading to reduced cardiac output.
D. Pericardial friction rub: A pericardial friction rub is a classic finding in acute pericarditis due to inflamed pericardial surfaces rubbing together, but it is not typically heard in cardiac tamponade, where fluid accumulation muffles heart sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Ferrous sulfate: Ferrous sulfate is an iron supplement and does not directly interact with warfarin's anticoagulant effect. While some mild interactions are possible, it is not generally contraindicated unless specifically advised due to individual clinical conditions.
B. Aspirin: Aspirin has antiplatelet effects and can increase the risk of bleeding when taken with warfarin. The combination enhances anticoagulation and significantly raises the chance of gastrointestinal or systemic bleeding.
C. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can interfere with platelet function and irritate the gastrointestinal lining, increasing the risk of bleeding when combined with warfarin.
D. Echinacea: Echinacea may interfere with liver enzyme activity and affect the metabolism of warfarin, potentially altering its effectiveness. Herbal supplements can cause unpredictable interactions and should generally be avoided while on warfarin.
E. Dextromethorphan: Dextromethorphan is a common cough suppressant and does not have significant interactions with warfarin. It is generally considered safe for occasional use in clients taking anticoagulants.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}
Explanation
Rationale:
- Troponin I level: An elevated troponin I level indicates myocardial cell injury and is a key diagnostic marker for MI. Even a value at the upper limit of normal (0.03 ng/mL) warrants concern, especially with accompanying symptoms.
- ECG result – sinus tachycardia: Sinus tachycardia is nonspecific but may occur in both MI and angina due to pain, anxiety, or sympathetic stimulation. However, more definitive MI-related changes like ST elevation or Q waves would provide clearer diagnostic value.
- Heart rate: A heart rate of 116/min is elevated and may represent the body’s response to pain, hypoxia, or stress. This can be seen in both angina and MI, though persistent or worsening tachycardia in MI may indicate hemodynamic instability.
- Heart palpitations: Palpitations are common during episodes of angina and are often due to increased sympathetic tone or transient arrhythmias. They are usually mild and resolve with rest or nitroglycerin in stable angina.
- Blood pressure: A blood pressure of 158/92 mm Hg indicates hypertension, a known trigger and risk factor for angina. Elevated BP increases myocardial oxygen demand, potentially precipitating chest pain in those with coronary artery disease.
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