Patho Patho #90

Question

Which are considered expected findings in a client with cardiac tamponade?

Answers

  1. Muffled heart sounds and hypotension.
    • Rationale:

      This answer is correct because cardiac tamponade results in hypotension due to decreased cardiac output and distant heart sounds which results from fluid build up within the pericardial sac.

  2. Weak peripheral pulses and hypertension.
    • Rationale:

      This answer choice is not correct because the client will not be hypertensive but rather the client will be hypotensive.

  3. Wide pulse pressure and negative Homan’s sign.
    • Rationale:

      This answer choice is not correct because the client will have a narrow pulse pressure and not a widened pulse pressure.

  4. Elevated white blood count and tachycardia.
    • Rationale:

      This answer choice is not correct because fever is not associated with cardiac tamponade. Cardiac tamponade is not an infectious process so fever is not an expected manifestation.

Overview

The focus of this question is asking the nurse to identify which clinical findings are expected in a client with a diagnosis of cardiac tamponade. Cardiac tamponade occurs when fluid builds up within the pericardial sac placing pressure on the heart throughout the cardiac cycle. Expected findings associated with cardiac tamponade include muffled heart sounds, hypotension, and pulsus paradoxus.

Explanation

Learning Outcomes

Cardiac tamponade occurs when a pericardial effusion is severe enough to actually cause compression on the heart due to fluid build up within the pericardial sac. Cardiac tamponade may occur gradually in clients with pre-existing pericardial effusion or it may have an abrupt onset. Symptoms of cardiac tamponade include symptoms associated with cardiogenic shock including dyspnea, fatigue and other signs of decreased cardiac output. Heart sounds will more than likely be distant or muffled and the client will be hypotensive due to decreased cardiac output.

Test Taking Tip

Always learn the UNIQUE and EXPECTED findings associated with disease processes as opposed to memorizing all signs/ symptoms.

Video Rationale