A nurse is providing teaching to newly licensed nurses about cardiac tamponade. Which of the following should the nurse include when teaching about Phase Il cardiac tamponade?

Comply with compression therapy.

Monitor wounds on lower extremities.

Take antiplatelet medications as ordered.

Monitor for gradual onset of symptoms

Answer and Explanation

The Correct Answer is D

A. Comply with compression therapy:

Compression therapy typically refers to the use of compression garments or devices to improve circulation and reduce swelling in the extremities, particularly in conditions such as venous insufficiency or deep vein thrombosis.

While compression therapy may be beneficial for certain circulatory disorders, it is not a standard treatment for cardiac tamponade.

Cardiac tamponade is a medical emergency characterized by the accumulation of fluid in the pericardial sac, leading to increased pressure on the heart and impaired cardiac function.

Treatment for cardiac tamponade involves prompt recognition and intervention to relieve the pressure on the heart, such as pericardiocentesis or surgical drainage of the pericardial effusion.

B. Monitor wounds on lower extremities:

Monitoring wounds on the lower extremities is essential for assessing healing, preventing complications such as infection, and promoting overall wound care.

However, monitoring wounds on the lower extremities is not directly related to the management or monitoring of cardiac tamponade.

In cardiac tamponade, the focus of monitoring is on assessing signs and symptoms of cardiac compromise, such as hypotension, tachycardia, dyspnea, and pulsus paradoxus, rather than wound care.

C. Take antiplatelet medications as ordered:

Antiplatelet medications, such as aspirin or clopidogrel, are commonly prescribed to prevent platelet aggregation and reduce the risk of thrombotic events, particularly in patients with cardiovascular disease or a history of myocardial infarction or stroke.

While antiplatelet medications may be part of the long-term management of certain cardiac conditions, they are not specific to the treatment or monitoring of cardiac tamponade.

The primary treatment for cardiac tamponade involves interventions to relieve the pressure on the heart and restore cardiac function, such as pericardiocentesis or surgical drainage of the pericardial effusion.

D. Monitor for gradual onset of symptoms:

Phase II of cardiac tamponade is characterized by a gradual onset of symptoms as the pressure within the pericardial sac increases, leading to impaired cardiac filling and decreased cardiac output.

Symptoms may include dyspnea, fatigue, orthopnea, tachycardia, and chest discomfort, which may develop gradually over time.

Early recognition of symptoms is crucial for prompt diagnosis and intervention to prevent further deterioration and improve outcomes in patients with cardiac tamponade.

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Correct Answer is A

Explanation

Answer: A. Ensuring that the client and their family are kept informed about the client's care

Rationale:

A. Ensuring that the client and their family are kept informed about the client's care:
This action is the priority because communication is vital in managing a client with multiple organ dysfunction syndrome (MODS). Keeping the client and their family informed can help them understand the seriousness of the condition, the plan of care, and potential outcomes. It also fosters trust and ensures that the family can make informed decisions regarding the client's care.

B. Being aware of the client's wishes regarding care:
While being aware of the client’s wishes is important, especially in critical conditions like MODS, the priority lies in ensuring ongoing communication about the client's current status and treatment. Understanding the client's wishes can guide care but should follow the immediate need for clear communication about the evolving situation.

C. Scheduling periods of rest for the client:
Rest is essential for recovery, particularly in clients with MODS, but scheduling rest periods is a part of implementing care rather than a primary action. It can be planned based on the client’s needs and condition but does not take precedence over ensuring that the family is informed.

D. Discussing the client's resting times with the family:
While involving the family in discussions about the client's care is beneficial, the immediate priority is to ensure they are fully informed about the overall condition and care plan. This discussion can occur after establishing a solid communication foundation regarding the client's status and care approach.

A. Diminished hair growth on the lower extremities B. Loss of pigmentation over the shin area C. Shiny appearance to the lower extremities D. Swollen and enlarged veins

Correct Answer is D

Explanation

A. Diminished hair growth on the lower extremities: Diminished hair growth on the lower extremities is not typically a manifestation of peripheral venous disease. Instead, it may suggest poor circulation or arterial insufficiency.

B. Loss of pigmentation over the shin area: Loss of pigmentation over the shin area can occur in conditions such as chronic venous insufficiency, which is a form of peripheral venous disease. However, it is not the most characteristic manifestation.

C. Shiny appearance to the lower extremities: A shiny appearance to the lower extremities is often associated with arterial insufficiency rather than peripheral venous disease. It can indicate thinning of the skin due to poor circulation and oxygenation.

D. Swollen and enlarged veins: Swollen and enlarged veins, also known as varicose veins, are classic manifestations of peripheral venous disease. These veins result from venous insufficiency, which leads to blood pooling and increased pressure in the veins, causing them to dilate and become visibly enlarged.

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A nurse is providing teaching to newly licensed nurses about cardiac tamponade. Which of the following should the nurse include when teaching about Phase Il cardiac tamponade?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Rationale:

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Correct Answer is D

Explanation

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