A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?
Pleural friction rub
Distended neck veins
Widening pulse pressure
Bradycardia .
The Correct Answer is B
Choice A rationale
A pleural friction rub is an audible raspy breathing sound, a medical sign present in some patients with pleurisy and other conditions affecting the chest cavity. It is not a typical symptom of cardiac tamponade.
Choice B rationale
Distended neck veins are a result of the collapsed blood vessels that should return blood to the heart. This is a common symptom of cardiac tamponade.
Choice C rationale
Widening pulse pressure occurs with valvular heart disease, not typically with cardiac tamponade.
Choice D rationale
Bradycardia, or a slower-than-normal heart rate, is not typically associated with cardiac tamponade.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.
Correct Answer is D
Explanation
Choice A rationale
While calf tenderness and swelling after a plane ride could potentially indicate a deep vein thrombosis, this condition is not immediately life-threatening in most cases. The patient would need evaluation and treatment, but other patients might have more urgent needs14.
Choice B rationale
A patient taking anticoagulants for atrial fibrillation who has black stools could potentially have gastrointestinal bleeding, which would need evaluation. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice C rationale
A patient with a gangrenous foot ulcer and a weak pedal pulse would need evaluation and treatment. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice D rationale
A patient reporting sudden sharp and severe upper back pain could potentially have an aortic dissection, which is a life-threatening condition that requires immediate evaluation and treatment. Therefore, this patient should be assessed first14.
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