A nurse is caring for a patient diagnosed with pericarditis
Due to this patient's risk for cardiac tamponade, the nurse is vigilant about assessing for which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Heart sounds that are more difficult to auscultate
2. A palpable lift at the third intercostal space just left of the midclavicular line
3. Decreased systolic blood pressure
4. Visible distention of jugular veins
5. Patient report of headache
1,3,4
Rationale 1: Muffling of heart sounds is one component of Beck's triad, the classic assessment findings of cardiac tamponade.
Rationale 2: Cardiac tamponade compresses the heart, which would decrease wall motion. Lifts are caused by increased force of contraction.
Rationale 3: Decreased blood pressure is one component of Beck's triad, the classic assessment findings of cardiac tamponade.
Rationale 4: Jugular venous distention is one component of Beck's triad, the classic assessment findings of cardiac tamponade.
Rationale 5: Headache is not associated with cardiac tamponade.
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