13. During a physical assessment of a client with cardiac tamponade, a nurse should expect to find:
Select all that apply.
13. During a physical assessment of a client with cardiac tamponade, a nurse should expect to find:
Select all that apply.
. A widened pulse pressure.
. Jugular venous distention (JVD).
. Loud heart sounds.
. Bounding pulses.
. Muffled heart sounds.
Test-Taking Tip
Correct options describe cardiac compromise and Beck's triad—JVD, muffled heart sounds, and hypotension.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because the failing heart cannot maintain a normal cardiac output and the pulse pressure narrows, not widens. Hypotension is one of the three classic indications of cardiac tamponade called Beck's triad. Answer 2 is correct because increased intracardiac pressure causes impaired filling of the right atrium, resulting in JVD. JVD is one of the three indicators of cardiac tamponade known as Beck's triad. Answer 3 is incorrect because contractility is hindered, and heart sounds are muffled from the fluid in the pericardium, not loud. Answer 4 is incorrect because the impaired cardiac contractility diminishes cardiac output. Answer 5 is correct because muffled heart sounds occur due to fluid inside the pericardium. Muffled heart sounds are one of the three indicators of cardiac tamponade known as Beck's triad.