When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?

Pleural friction rub.

Distended neck veins.

Widening pulse pressure.

Bradycardia.

Answer and Explanation

The Correct Answer is B

Choice A rationale
A pleural friction rub, which is a grating sound caused by the inflammation of the pleural surfaces during respiration, is not typically associated with cardiac tamponade. It is more commonly associated with conditions affecting the lungs, such as pneumonia or pleurisy.
Choice B rationale
Distended neck veins are a classic sign of cardiac tamponade. This occurs due to increased pressure in the right atrium as a result of the impaired filling of the ventricles. This is a critical sign that should be reported immediately.
Choice C rationale
Widening pulse pressure (an increase in the difference between systolic and diastolic blood pressure) is not typically associated with cardiac tamponade. In fact, cardiac tamponade more commonly presents with a narrowed pulse pressure.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of cardiac tamponade. More commonly, tachycardia, or a fast heart rate, is observed in response to decreased cardiac output.

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Correct Answer is D

Explanation

Choice A rationale
The diaphragm is not typically the location of a coarctation of the aorta. The diaphragm is a muscle that helps with breathing and separates the chest cavity from the abdominal cavity.
Choice B rationale
The bifurcation into the common iliac arteries is not typically the location of a coarctation of the aorta. The common iliac arteries are located in the lower part of the aorta and supply blood to the pelvis and legs.
Choice C rationale
The aortic valve is not typically the location of a coarctation of the aorta. The aortic valve is located between the left ventricle of the heart and the aorta.
Choice D rationale
The ductus arteriosus is the correct answer. Coarctation of the aorta often occurs near the ductus arteriosus, a blood vessel that connects the left pulmonary artery to the aorta.

A. Elevate the leg above the level of the heart. B. Assist the patient in gently exercising the leg. C. Apply a compression stocking to the leg. D. Keep the patient in bed in the supine position.

Correct Answer is D

Explanation

Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.

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When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Coarctation of the aorta refers to the local narrowing of the aorta near which location?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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