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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Ulceration on the medial surface of the lower legs is not the best description of stasis dermatitis in a patient with peripheral vascular disease (PVD). While ulcers can occur in severe cases, they are not the primary characteristic of stasis dermatitis.
Choice B rationale
Stasis dermatitis, also known as venous stasis dermatitis, is a skin inflammation that occurs in people with poor circulation. It most often happens in the lower legs because that’s where blood typically collects. When blood pools in the veins of the lower leg, it can cause a variety of symptoms, including a brownish skin discoloration on the lower legs. This discoloration is caused by the leakage of red blood cells into the skin due to increased pressure in the veins.
Choice C rationale
While edema in the lower legs can be a symptom of PVD and may accompany stasis dermatitis, it is not the best description of the condition. Edema is a general symptom that can occur in many conditions and is not specific to stasis dermatitis.
Choice D rationale
A purple rash on the medial surface of the lower legs is not a typical symptom of stasis dermatitis. While the skin may become discolored, it is usually a brownish color rather than purple.

A. Cyanosis and hypoxia B. High-pitched cry and dyspnea C. Leg pain and twitching D. Epistaxis and anemia

Correct Answer is A

Explanation

Choice A rationale
Tetralogy of Fallot is a congenital heart condition that presents with a combination of four defects in the structure of the heart. The most common symptoms in a newborn with this condition include cyanosis (bluish color of the skin due to reduced oxygen in the blood) and hypoxia (low levels of oxygen in the body)34567.
Choice B rationale
While a high-pitched cry can be a sign of distress in a newborn, it is not specifically associated with tetralogy of Fallot. Dyspnea (difficulty breathing) can occur in severe cases, but it is not one of the primary symptoms of this condition.
Choice C rationale
Leg pain and twitching are not typical symptoms of tetralogy of Fallot. These symptoms could be indicative of other conditions, but they are not associated with this specific congenital heart defect.
Choice D rationale
Epistaxis (nosebleeds) and anemia are not typical symptoms of tetralogy of Fallot. While these conditions can occur in children for various reasons, they are not directly related to this specific congenital heart defect.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

How would a nurse best describe the assessment of stasis dermatitis in a patient with peripheral vascular disease (PVD)?

Correct Answer is B

Explanation

A newborn child has been diagnosed with tetralogy of Fallot. What symptoms would the nurse expect to observe in this child?

Correct Answer is A

Explanation

A 35-year-old patient presents with pulmonary hypertension and is diagnosed with right heart failure. What is the most likely cause of this condition?

After receiving a change-of-shift report, which patient admitted to the emergency department should the nurse assess first?

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

An obese post-surgical patient reports sudden discomfort in her leg. Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

What nursing assessment finding would suggest inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome (myocardial infarction)?

What is the most important nursing action in caring for a patient who has just recovered from rheumatic fever?

The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet. What does the nurse understand these to be?