The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?

Muffled heart sounds

Jugular venous distention

Client reports dyspnea

Client expresses immediate relief

Answer and Explanation

The Correct Answer is D

A.   Muffled heart sounds can be a sign of cardiac tamponade, but they should improve after a successful pericardiocentesis.
B.   Jugular venous distention is another sign of cardiac tamponade. If the procedure was effective, the jugular venous distention should decrease.
C.   Dyspnea is a common symptom of cardiac tamponade. If the procedure was effective, the client should experience relief from dyspnea.
D.   This procedure involves draining excess fluid from the pericardial sac, which can provide immediate relief from the symptoms of cardiac tamponade. If the procedure was effective, the client should experience immediate relief from their symptoms, such as chest pain, shortness of breath, and tachycardia.

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Correct Answer is C

Explanation

A. Left ventricular hypertrophy (LVH) refers to the thickening of the walls of the left ventricle, which often results from chronic high blood pressure or other conditions that increase the workload on the heart. While LVH is an important cardiac issue, it is not a direct complication of pericarditis.
B. Increased cardiac output (the volume of blood the heart pumps per minute) is generally not a direct complication of pericarditis. In fact, pericarditis often affects cardiac output in a different way.
C. Cardiac tamponade is a serious and potentially life-threatening complication of pericarditis. It occurs when fluid accumulates in the pericardial space, exerting pressure on the heart and impeding its ability to fill and pump effectively. This condition can lead to reduced cardiac output, hypotension, and symptoms of shock.
D. Hypertension (high blood pressure) is a common condition that can contribute to a range of cardiovascular issues, but it is not a direct complication of pericarditis.

A. hypertrophy of the right ventricle. B. superior vena cava syndrome. C. valvular heart disease. D. pulmonary hypertension.

Correct Answer is C

Explanation

A. Hypertrophy of the right ventricle refers to the thickening of the walls of the right ventricle of the heart. Hypertrophy of the right ventricle is not a typical consequence of rheumatic fever. Instead, rheumatic fever more commonly affects the heart valves.
B. Superior vena cava syndrome occurs when there is obstruction of the superior vena cava, which is a major vein that carries blood from the head, neck, and upper body to the heart. It is not a direct consequence of rheumatic fever.
C. Valvular heart disease is a significant long-term consequence of rheumatic fever. Rheumatic fever can cause inflammation of the heart valves, leading to damage that may result in stenosis (narrowing) or regurgitation (leakage) of the valves. The mitral and aortic valves are most commonly affected. This damage can progress over time and lead to chronic heart problems, including valvular heart disease.
D. Pulmonary hypertension refers to high blood pressure in the arteries of the lungs. It can be caused by various conditions, including chronic lung diseases and left heart disease. While rheumatic fever primarily affects the heart valves and can potentially lead to heart failure, it is not a direct cause of pulmonary hypertension.

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The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?

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