The nurse is planning care for a client with pericarditis. Which intervention assesses for the potential complication of cardiac tamponade?

Check current WBC count

Assess for hypertension

Auscultate heart sounds

Measure blood glucose

Answer and Explanation

The Correct Answer is C

a. Check current WBC count: While an elevated white blood cell (WBC) count may indicate inflammation, it is not specific to the assessment of cardiac tamponade. WBC count may be elevated in pericarditis due to the inflammatory process, but it does not directly assess for the potential complication of cardiac tamponade.

b. Assess for hypertension: Hypertension is not typically associated with cardiac tamponade. Instead, cardiac tamponade is characterized by hemodynamic compromise, which may manifest as hypotension rather than hypertension. While assessing blood pressure is important in overall cardiovascular assessment, it is not specific to detecting cardiac tamponade.

c. Auscultate heart sounds: Auscultating heart sounds, specifically for the presence of muffled heart sounds (reduced intensity of heart sounds) and distant heart sounds, is a key assessment for detecting cardiac tamponade, a potential complication of pericarditis. Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing cardiac filling. This can lead to hemodynamic compromise and potentially life-threatening consequences. Muffled or distant heart sounds are classic signs of cardiac tamponade and indicate the need for immediate intervention.

d. Measure blood glucose: Blood glucose measurement is not directly related to the assessment of cardiac tamponade. While monitoring blood glucose levels may be important in clients with diabetes or those at risk of hyperglycemia, it does not provide information specific to the detection of cardiac tamponade.

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Correct Answer is A

Explanation

a. BNP 700pg/ml (<100pg/ml)

Rationale: B-type natriuretic peptide (BNP) is a biomarker used to diagnose and assess the severity of heart failure. Elevated BNP levels indicate increased ventricular stretch and fluid overload, both of which are indicative of worsening heart failure. A BNP level of 700pg/ml is significantly elevated compared to the normal range (<100pg/ml) and suggests acute exacerbation or decompensation of heart failure, requiring prompt intervention and management adjustment.

b. Chest x-ray shows cardiomegaly: While cardiomegaly on chest x-ray is indicative of heart failure, it is a diagnostic finding rather than an acute result requiring immediate intervention. It would be important to address but may not require urgent reporting unless accompanied by acute symptoms.

c. Hematocrit 35% (37-47%): A hematocrit of 35% falls at the lower end. While changes in hematocrit can indicate fluid volume status, this value alone does not indicate an urgent need for intervention or adjustment of therapy. It may warrant monitoring over time, but it is not an immediate concern.

d. Echocardiogram with ejection fraction of 60% (normal is 55-75%): An ejection fraction of 60% falls within the normal range and is not indicative of worsening heart failure. While it's essential to monitor ejection fraction in heart failure patients, this result alone does not suggest acute decompensation requiring immediate intervention.

A. Warm flushed extremities B. Increased urine output C. Orthostatic hypotension D. Decreased skin turgor

Correct Answer is C

Explanation

a. Warm flushed extremities: In acute heart failure, there is typically inadequate cardiac output to perfuse the peripheral tissues adequately. This can lead to vasoconstriction and decreased blood flow to the extremities, resulting in cool and pale or mottled skin rather than warm flushed extremities.

b. Increased urine output: Acute heart failure is characterized by impaired cardiac function, which can lead to decreased cardiac output and reduced renal perfusion. This can result in decreased urine output rather than increased urine output. In acute heart failure, the kidneys may activate compensatory mechanisms such as the renin-angiotensin-aldosterone system, leading to sodium and water retention and decreased urine output.

c. Orthostatic hypotension: Orthostatic hypotension, a drop in blood pressure upon standing, is not typically associated with acute heart failure. Instead, acute heart failure is more commonly associated with signs and symptoms of fluid overload such as peripheral edema, pulmonary congestion, and jugular venous distension.

d. Decreased skin turgor: Decreased skin turgor is not a typical finding in acute heart failure. It is more commonly associated with dehydration or volume depletion rather than acute heart failure, which is characterized by fluid overload.

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The nurse is planning care for a client with pericarditis. Which intervention assesses for the potential complication of cardiac tamponade?

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