A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?

Rationale:

A. The nurse provides wound care to a client at the time promised to the client: Providing care as scheduled reflects reliability and professionalism, but it does not involve speaking up for or securing specific services in the client's best interest, which defines advocacy.

B. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services: This demonstrates advocacy by ensuring the client has access to specialized care that supports comfort, dignity, and symptom management—especially important in progressive, life-limiting illness.

C. The nurse declines to inform a client's neighbor about the client's prognosis: This action protects client confidentiality and privacy, which is ethically correct, but it does not represent active support or promotion of the client's needs or preferences.

D. The nurse files an incident report regarding a medication error: Filing an incident report supports patient safety and institutional accountability. However, it does not reflect direct advocacy, as it does not involve pursuing specific care or services for the client.

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.