Question

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which assessment finding should the nurse expect?

A. Increased blood pressure
B. Elevated temperature
C. Muffled heart sounds
D. Bradycardia

Answer 1

In a case of cardiac tamponade, a nurse in the emergency department would expect to find muffled heart sounds upon assessment, which occurs due to fluid accumulation muffling the 'lub-dub' sounds of the heart valves.

Step-by-step explanation:

In the emergency department, when assessing a client who has cardiac tamponade, the nurse should expect to find muffled heart sounds as a key assessment finding. This is because cardiac tamponade involves the accumulation of excess fluid, often blood, in the pericardial space, which compresses the heart and impairs its ability to pump effectively. Other classic signs of cardiac tamponade, commonly known as Beck's triad, may include hypotension (low blood pressure) and jugular venous distension, although these are not options provided in the question. Muffled heart sounds occur due to the fluid in the pericardium creating a layer of insulation around the heart, impeding the transmission of sound, and therefore, the normal 'lub-dub' sounds of the heart valves closing are harder to hear with a stethoscope. The response to the presented question is C. Muffled heart sounds.