A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?
A.
Pleural friction rub
B.
Distended neck veins
C.
Widening pulse pressure
D.
Bradycardia .
The Correct Answer and Explanation is :
The correct answer is B. Distended neck veins.
Explanation
Cardiac tamponade is a condition where fluid accumulates in the pericardial space, the sac surrounding the heart. This accumulation creates pressure that impairs the heart’s ability to pump effectively. The symptoms and clinical signs of cardiac tamponade are related to this impaired cardiac function.
Distended Neck Veins (Option B): One of the hallmark signs of cardiac tamponade is jugular vein distention. The increased intrapericardial pressure impedes the heart’s ability to fill properly during diastole, leading to elevated central venous pressure. This increased pressure is transmitted to the jugular veins, resulting in visible distention. This finding is due to the backpressure of blood that the right side of the heart cannot effectively handle due to compromised filling capacity.
Pleural Friction Rub (Option A): This is typically associated with pleuritis or inflammation of the pleura, not cardiac tamponade. A pleural friction rub is a grating sound heard on auscultation of the lungs and is unrelated to pericardial fluid accumulation.
Widening Pulse Pressure (Option C): This is usually seen in conditions such as aortic regurgitation or severe sepsis, rather than in cardiac tamponade. Cardiac tamponade often presents with a narrowed pulse pressure (the difference between systolic and diastolic blood pressure), due to the impaired filling of the heart and compromised stroke volume.
Bradycardia (Option D): Bradycardia is not a direct sign of cardiac tamponade. In fact, cardiac tamponade more commonly presents with tachycardia as the body attempts to compensate for reduced cardiac output.
Overall, the most expected symptom in cardiac tamponade among the provided options is distended neck veins. This symptom is a direct result of elevated central venous pressure and impaired venous return to the heart. Other symptoms might include hypotension, muffled heart sounds, and pulsus paradoxus (a drop in blood pressure during inspiration).