While caring for a patient with thoracic injuries from a motor vehicle crash, the nurse suspects the patient is developing cardiac tamponade because of which assessment findings? Note: Credit will be given only if all correct choices and no
incorrect choices are selected. Select all that apply. 1. Dropping blood pressure
2. Jugular vein distention
3. Muffled heart sounds
4. Drop in blood pressure on inspiration
5. Increase in blood pressure on inspiration
1,2,3,4
Rationale 1: Hypotension is an assessment finding within Beck's triad indicating cardiac tamponade.
Rationale 2: An increase in central venous pressure assessed as jugular vein distention is an assessment finding within Beck's triad indicating cardiac tamponade.
Rationale 3: Heart sounds are muffled in cardiac tamponade because of the accumulation of fluid in the pericardial sac. This is an assessment finding within Beck's triad indicating cardiac tamponade.
Rationale 4: In paradoxical pulse, blood pressure is at least 10 mm Hg higher on expiration than on inspiration. This is an assessment finding of cardiac tamponade.
Rationale 5: In cardiac tamponade, the blood pressure is higher on expiration than inspiration.
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