Medical Surgical Cardiac Tamponade #3

Question

A client arrives at the emergency room following a stab wound to the chest. Which emergent complication will the nurse carefully monitor the client for in the emergency department?

Answers

  1. Systemic infection
    • Rationale:

      This answer is not correct because although a systemic infection could occur related to a stab wound, it would not occur immediately and is not a cause of cardiac tamponade. An infection to the pericardial sac can cause this condition but that would be something that could occur later, not when the client is in the emergency room. A stab wound to the chest is a high risk condition that can cause cardiac tamponade so the nurse should monitor the client carefully for this.

  2. Cardiac tamponade
    • Rationale:

      This answer is correct because causes of cardiac tamponade include trauma (stab wound) to the chest, infection of the pericardial sac, reaction to certain medications, chest radiation, cancer, and autoimmune diseases. A stab wound to the chest is a high risk condition that can cause cardiac tamponade so the nurse should monitor the client carefully for this. Cardiac tamponade is a serious medical emergency in which blood or other fluids fill the pericardial space (the sac that surrounds the heart). This extra fluid places increased pressure on the heart to the extent that the ventricles cannot fill and contract.

  3. Infective endocarditis
    • Rationale:

      This answer is not correct because infective endocarditis is an infection involving the valves of the heart, not the pericardial sac. An infection to the pericardial sac can cause this condition, but not an infection involving the valves of the heart. A stab wound to the chest is a high risk condition that can cause cardiac tamponade so the nurse should monitor the client carefully for this.

  4. Myocardial infarction
    • Rationale:

      This answer is not correct because although the client could be at risk for cardiac tamponade related to inflammation of the pericardial sac from a heart attack, the client would not be at emergent risk for a myocardial infarction related to a stab wound. A stab wound to the chest is a high risk condition that can cause cardiac tamponade so the nurse should monitor the client carefully for this.

Overview

An emergent complication associated with a chest stab wound is cardiac tamponade.

Explanation

Learning Outcomes

Cardiac tamponade is a serious medical emergency in which blood or other fluids fill the pericardial space (the sac that surrounds the heart). This extra fluid places increased pressure on the heart to the extent that the ventricles cannot fill and contract. There is then no cardiac output. The classic clinical manifestations of cardiac tamponade are considered hypotension, jugular vein distention (JVD), and muffled heart tones. Other symptoms that occur include shortness of breath, weakness, anxiety, chest pain, loss of consciousness as cardiac output decreases. Immediate pericardiocentesis (removal of the excessive fluid in the pericardium) is the treatment. Causes of cardiac tamponade include trauma to the chest, infection of the pericardial sac, reaction to certain medications, chest radiation, cancer, and autoimmune diseases.

Test Taking Tip

Be sure to read the question and understand what can cause a condition and what can occur related to a condition. Wording of the question is important to understand.

Video Rationale