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 A

Explanation

Choice A rationale
Stable angina typically occurs with exertion and goes away with rest. The symptoms described, including substernal pain, discomfort in the left shoulder and jaw, which subside with rest, are characteristic of stable angina.
Choice B rationale
Prinzmetal angina, also known as variant angina, is a type of angina (chest pain) caused by spasms in the coronary arteries. These spasms occur most often in coronary arteries that have not become hardened due to plaque buildup. However, they can also occur in hardened arteries. The symptoms can be similar to those of stable angina, but the typical triggers for the episodes are different.
Choice C rationale
A myocardial infarction (MI), or heart attack, occurs when one of the coronary arteries becomes blocked, often by a blood clot, causing part of the heart muscle to be damaged or die. The symptoms are usually more severe than what is described and do not typically subside with rest.
Choice D rationale
Unstable angina is a condition in which the angina symptoms become more severe, occur more frequently, or occur at rest. This is a medical emergency as it can often lead to a heart attack.

A. A 39-year-old patient who has right calf tenderness and swelling after a plane ride B. A 58-year-old patient taking anticoagulants for atrial fibrillation who has black stools C. A 67-year-old patient who has a gangrenous foot ulcer with a weak pedal pulse D. A 50-year-old patient who is reporting sudden sharp and severe upper back pain .

Correct Answer is D

Explanation

Choice A rationale
While calf tenderness and swelling after a plane ride could potentially indicate a deep vein thrombosis, this condition is not immediately life-threatening in most cases. The patient would need evaluation and treatment, but other patients might have more urgent needs14.
Choice B rationale
A patient taking anticoagulants for atrial fibrillation who has black stools could potentially have gastrointestinal bleeding, which would need evaluation. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice C rationale
A patient with a gangrenous foot ulcer and a weak pedal pulse would need evaluation and treatment. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice D rationale
A patient reporting sudden sharp and severe upper back pain could potentially have an aortic dissection, which is a life-threatening condition that requires immediate evaluation and treatment. Therefore, this patient should be assessed first14.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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