A trauma client who has experienced a blunt cardiac injury from a steering wheel should be assessed for cardiac tamponade. Which of the following clinical manifestations would the nurse be assessing for?
1. Neck vein distention, muffled heart sounds, hypotension
2. Jugular vein distention, bounding pulse, harsh murmur
3. Bilateral upper arm distention, hypertension, edema of the face
4. Absent breath sounds on the left, apical pulse displaced to the left, S3 heart gallop
Neck vein distention, muffled heart sounds, hypotension
Rationale: Neck vein distention is caused by elevated central venous pressure, muffled heart sounds is due to the amount of blood surrounding the heart, and hypotension is due to blood loss (i.e., shock). Bounding pulse is usually seen in hypervolemic states.
Bilateral arm distention is usually caused by pressure placed on the superior vena cava, which is not related to cardiac tamponade. Murmurs are due to valvular disease. Absent breath sounds are pulmonary problems. A displaced apical pulse is usually a result of hypertrophy of the heart. S3 gallop is a classic sign of heart failure.
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