HESI Registered Nurse EXIT Practice Exam

What finding would a nurse anticipate in a client with cardiac tamponade?

1. Widening pulse pressure

2. Pleural friction rub

3. Distended neck veins

4. Bradycardia

The correct answer is: Distended neck veins

In a client with cardiac tamponade, the nurse would anticipate finding distended neck veins. Cardiac tamponade occurs when fluid accumulates in the pericardial space, exerting pressure on the heart and impeding its ability to fill properly during diastole. This decreased filling can lead to increased venous pressure, which manifests as distended neck veins. As the heart struggles to pump effectively due to the external pressure from fluid accumulation, blood can back up into the veins that drain into the heart, particularly the superior vena cava. As a result, the jugular veins, which are visible in the neck, become distended. This finding is a significant clinical indicator of elevated central venous pressure and is often associated with the classic triad of symptoms in cardiac tamponade, known as Beck's triad, which includes hypotension, muffled heart sounds, and elevated jugular venous pressure. While the other findings, such as a widening pulse pressure, pleural friction rub, and bradycardia, can occur in various cardiovascular conditions, they are not characteristic of cardiac tamponade. A widening pulse pressure may suggest disassociation in systolic and diastolic pressures, pleural friction rub indicates pleuritis rather than cardiac