A trauma patient who experienced blunt cardiac injury from a steering wheel should be assessed for cardiac tamponade
The nurse would assess for which clinical manifestations? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Neck vein distention
2. Presence of an S3 heart sound
3. Muffled heart sounds
4. Bounding pulse
5. Hypotension
1,3,5
Rationale 1: Neck vein distention is caused by elevation of central venous pressure.
Rationale 2: S3 heart sounds are related to fluid volume overload and are not expected with cardiac tamponade.
Rationale 3: The presence of blood in the pericardial sac results in muffling of the heart sounds.
Rationale 4: The heart is being squeezed by the hydraulic pressure of blood in the pericardial sac. The pulse will be diminished, not bounding.
Rationale 5: Hypotension results from decreased cardiac output.
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