The nurse is assessing a patient following a cardiac catheterization.
On assessment, they note muffled heart sounds, jugular vein distention, and hypotension.
The nurse knows these are signs of what?
Cardiac tamponade
Artery dissection
These are normal findings following stent placement
Myocardial Infarction
The Correct Answer is A
Cardiac tamponade is a life-threatening condition that occurs when fluid accumulates in the pericardial sac, the thin, doublelayered membrane that surrounds the heart. This fluid buildup compresses the heart, preventing it from filling properly and pumping blood effectively.
The classic triad of symptoms of cardiac tamponade is muffled heart sounds, jugular vein distention (JVD), and hypotension.
Muffled heart sounds occur because the fluid in the pericardial sac dampens the sound of the heart's valves closing. JVD occurs because the fluid in the pericardial sac compresses the superior vena cava, which is a large vein that carries blood from the upper body back to the heart. Hypotension occurs because the compressed heart is unable to pump blood effectively.
Other signs and symptoms of cardiac tamponade may include:
Tachycardia (rapid heart rate)
Dyspnea (shortness of breath)
Chest pain
Pulsus paradoxus (a drop in blood pressure during inspiration)
Anxiety or restlessness
Altered mental status
Cardiac tamponade is a medical emergency that requires immediate treatment. The goal of treatment is to relieve the pressure on the heart by removing the fluid from the pericardial sac. This is typically done through a procedure called pericardiocentesis, which involves inserting a needle into the pericardial sac and draining the fluid.
Choice B rationale:
Artery dissection is a condition that occurs when the inner layer of an artery tears, allowing blood to flow between the layers of the artery wall. This can lead to a number of complications, including aneurysm formation, rupture, and ischemia (lack of blood flow) to the organs and tissues supplied by the affected artery.
The signs and symptoms of artery dissection vary depending on the location of the dissection. Common symptoms include sudden, severe pain; weakness or numbness; and a difference in blood pressure between the arms or legs.
Artery dissection is a serious condition that requires prompt medical attention. Treatment options may include medication, surgery, or a combination of both.
Choice C rationale:
It is not normal to have muffled heart sounds, JVD, and hypotension following stent placement. These are signs of a serious complication, such as cardiac tamponade or artery dissection.
Choice D rationale:
Myocardial infarction (MI), also known as a heart attack, occurs when blood flow to a portion of the heart is blocked, causing damage to the heart muscle. The classic symptom of an MI is chest pain, but other symptoms may include shortness of breath, nausea, vomiting, sweating, and lightheadedness.
The signs and symptoms of cardiac tamponade and MI can overlap, but there are some key differences. For example, chest pain is more common in MI, while JVD is more common in cardiac tamponade.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Pain relief is a primary benefit of morphine administration in the setting of myocardial infarction.
Pain can trigger a stress response, leading to increased heart rate, blood pressure, and myocardial oxygen demand.
Morphine effectively reduces pain, thereby lessening the stress response and its detrimental effects on the heart.
This helps to minimize myocardial ischemia and potential further damage to the heart muscle.
Pain control also improves patient comfort and overall well-being, which can indirectly contribute to better cardiac outcomes.
Choice B rationale:
Sedation is another important benefit of morphine in this context.
It promotes rest and relaxation, which can lower heart rate, blood pressure, and myocardial oxygen demand.
This is crucial for patients with myocardial infarction, as their hearts require reduced workload to heal and recover.
Sedation also helps to alleviate anxiety and agitation, which can further strain the heart.
By inducing a state of calmness, morphine can indirectly protect the heart from additional stress.
Choice C rationale:
While morphine does have diuretic effects, increasing urinary output is not a primary goal in the management of myocardial infarction.
In fact, excessive diuresis could potentially lead to dehydration and hypotension, which could be detrimental to cardiac function.
Therefore, while morphine may slightly increase urine output, this is not a major reason for its use in this setting.
Choice D rationale:
Decreasing myocardial demand is a key benefit of morphine administration in patients with myocardial infarction.
Morphine achieves this by:
Reducing pain and the associated stress response
Promoting sedation and relaxation
Diminishing anxiety and agitation
Exerting a direct vasodilatory effect on blood vessels
This collective action of morphine leads to a decrease in heart rate, blood pressure, and the heart’s overall workload.
As a result, the heart requires less oxygen and experiences reduced strain, allowing for better healing and recovery following a myocardial infarction.
Correct Answer is C
Explanation
Choice A rationale:
Metoprolol (Lopressor) is a beta-blocker that primarily affects the heart and blood vessels. It does not have a direct effect on the visual system, and therefore, it is not associated with the green-yellow halo symptom.
Common side effects of metoprolol include:
Fatigue
Bradycardia (slow heart rate)
Hypotension (low blood pressure)
Dizziness
Cold extremities
Bronchospasm (narrowing of the airways)
Diarrhea
Tinnitus (ringing in the ears)
Decreased exercise tolerance
Glucose intolerance
Masking of hypoglycemia symptoms Choice B rationale:
Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor that primarily affects the kidneys and blood vessels. It does not have a direct effect on the visual system, and therefore, it is not associated with the green-yellow halo symptom.
The most common side effect of enalapril is a dry cough. This cough is thought to be caused by an increase in bradykinin levels, which can lead to the constriction of bronchial smooth muscle.
Choice D rationale:
Furosemide (Lasix) is a loop diuretic that primarily affects the kidneys and fluid balance. It does not have a direct effect on the visual system, and therefore, it is not associated with the green-yellow halo symptom.
Toxicity with furosemide manifests as extensions of its diuretic activity. Signs and symptoms of overdose or toxicity include:
Dehydration
Reduced blood volume
Electrolyte imbalances, particularly hypokalemia (low potassium levels) Choice C rationale:
Digoxin (Lanoxin) is a cardiac glycoside that affects the heart's electrical activity and muscle contractions. It has a narrow therapeutic index, meaning that there is a small difference between the therapeutic dose and the toxic dose.
One of the most characteristic signs of digoxin toxicity is a visual disturbance known as the "green-yellow halo sign." This symptom is thought to be caused by the inhibition of an enzyme in the retina called Na+/K+-ATPase.
Other common signs and symptoms of digoxin toxicity include:
Nausea and vomiting
Anorexia (loss of appetite)
Fatigue
Headache
Confusion
Arrhythmias (irregular heartbeats)
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