During the assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Pulsus paradoxus
2. Muffled heart sounds
3. Hypotension
4. Flat jugular veins
1,2,3
Rationale 1: This is a symptom of cardiac tamponade.
Rationale 2: This is a symptom of cardiac tamponade.
Rationale 3: This is a symptom of cardiac tamponade.
Rationale 4: Jugular vein distention would increase, not decrease, with the increasing backup of blood and the decreasing contractility from the limited motion of the ventricles as fluid/blood builds up within the sac, limiting its ability to move.
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