Question

The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all.

A. Bradycardia
B. Pulsus paradoxus
C. Distant heart sounds
D. Falling BP
E. Distended neck veins

Answer 1

A nurse should look for pulsus paradoxus, distant heart sounds, and distended neck veins as signs of cardiac tamponade, a complication of acute pericarditis.

Step-by-step explanation:

The nurse monitoring a client with acute pericarditis should be vigilant for the signs of cardiac tamponade, a serious complication of pericarditis. When the pericardial space fills with excess fluid, it can prevent the heart from relaxing and filling with blood properly. The signs associated with cardiac tamponade that the nurse should monitor include:

• Pulsus paradoxus (a drop in blood pressure during inspiration by more than the usual 10 mm Hg)
• Distant heart sounds due to the fluid dampening the noise
• Distended neck veins, indicating increased central venous pressure

While bradycardia (A) and falling blood pressure (BP) (D) could be related to cardiac issues, they are not specific markers of cardiac tamponade and are, therefore, not selected.