Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased.
The nurse should collaborate with the other members of the care team to prevent the development of which complication?
Pulmonary edema.
Cardiac tamponade.
Pericarditis.
Pericardiocentesis.
The Correct Answer is B
Choice A rationale
Pulmonary edema occurs when fluid backs up into the lungs, usually due to left-sided heart failure. While pericardial fluid can affect heart function, pulmonary edema is not the most immediate or direct complication of fluid accumulation within the pericardial sac itself. Instead, the fluid in the sac creates external pressure on the heart. The focus of care for increased pericardial fluid is the restriction of cardiac filling rather than the primary congestion of the pulmonary vasculature.
Choice B rationale
Cardiac tamponade is a life-threatening condition where the accumulation of fluid in the pericardial sac increases intrapericardial pressure. This pressure prevents the heart chambers from expanding fully during diastole, which severely reduces stroke volume and cardiac output. Common signs include Beck's triad: hypotension, jugular venous distention, and muffled heart sounds. Immediate intervention is required because the heart can eventually stop beating entirely as it becomes unable to fill with blood due to external compression.
Choice C rationale
Pericarditis is the inflammation of the pericardium, which is often the underlying cause of fluid accumulation, known as pericardial effusion. While the nurse monitors for signs of inflammation, the question asks for a complication resulting from the fluid being dangerously increased. Pericarditis is the state of the tissue rather than the acute hemodynamic consequence of fluid volume. Therefore, preventing the functional collapse of the heart takes precedence over managing the inflammatory process in an emergency.
Choice D rationale
Pericardiocentesis is a medical procedure used to drain excess fluid from the pericardial sac to relieve pressure on the heart. It is a treatment modality rather than a complication. The nurse collaborates with the team to perform this procedure in order to treat or prevent cardiac tamponade. Since the question asks for a complication to prevent, choosing a treatment is logically incorrect. The goal is to avoid the physiological crisis that necessitates such an invasive intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The description of advancing a catheter to dilate a narrowed or occluded artery refers to percutaneous transluminal coronary angioplasty (PTCA). This procedure is specifically used to treat coronary artery disease by improving blood flow to the myocardium. It does not address the structural mechanical issues of a stenosed mitral valve. Mitral valve stenosis involves a narrowing of the valve orifice itself, requiring a procedure that targets the valvular apparatus rather than the coronary arteries.
Choice B rationale
Heparin is an anticoagulant used to prevent the formation or extension of blood clots but it is not a primary treatment for the mechanical narrowing found in mitral valve stenosis. While patients with mitral stenosis may receive anticoagulation to prevent systemic emboli if they are in atrial fibrillation, a heparin bolus and infusion will not physically widen the stenotic valve. Pharmacological therapies are indicated here to manage symptoms, whereas the question asks for other mechanical treatment options.
Choice C rationale
Pentoxifylline is a hemorheologic agent that improves blood flow by decreasing blood viscosity and increasing erythrocyte flexibility. It is primarily used to treat intermittent claudication in peripheral vascular disease. It does not have a role in the mechanical dilation of a stenosed mitral valve. It acts on the properties of the blood cells rather than the valvular tissue. Thus, it is an inappropriate teaching point for a client seeking non-pharmacological treatment for mitral valve stenosis.
Choice D rationale
This statement accurately describes a percutaneous balloon valvuloplasty. In this procedure, a balloon-tipped catheter is inserted through the femoral vein, advanced to the heart, and passed through the atrial septum to reach the mitral valve. Inflation of the balloon splits the fused commissures of the stenotic valve, thereby increasing the valve area and improving blood flow from the left atrium to the left ventricle. This is a common non-surgical intervention for symptomatic mitral valve stenosis.
Correct Answer is D
Explanation
Choice A rationale
Pulmonary embolism is a potential complication for any hospitalized patient due to immobility and venous stasis, but it is not the most common complication specifically following a myocardial infarction. While the risk of deep vein thrombosis exists, the primary pathological concerns after a heart attack are related to the damaged myocardium and the resulting electrical instability or mechanical failure of the heart pump, rather than venous thromboembolic disease.
Choice B rationale
Stroke can occur following a myocardial infarction, particularly if the patient develops atrial fibrillation or if a mural thrombus forms in the weakened left ventricle and embolizes. However, the incidence of stroke is lower compared to the immediate hemodynamic failures of the heart. While significant and life-altering, clinicians prioritize monitoring for heart failure and shock in the acute post-infarction period because these cardiac-specific complications occur with much higher frequency.
Choice C rationale
Acute renal failure can occur after a myocardial infarction as a result of decreased renal perfusion or "cardiorenal syndrome" when the heart can no longer maintain adequate mean arterial pressure. While kidneys are sensitive to drop-offs in cardiac output, this complication is usually secondary to the primary failure of the heart. It occurs less frequently as an immediate complication than cardiogenic shock, which represents the direct, catastrophic failure of the heart muscle itself.
Choice D rationale
Cardiogenic shock occurs when more than 40 percent of the left ventricular mass is infarcted, leading to a profound inability of the heart to maintain adequate systemic perfusion. This is the leading cause of in-hospital death following a myocardial infarction. The damaged muscle cannot generate enough force to maintain a stroke volume, leading to a cascade of hypotension and pulmonary edema. It remains the most common and feared major complication in the acute phase.
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