ATI Capstone Exam 2 Final | Nurselytic

Questions 116

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ATI Capstone Exam 2 Final Questions

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Question 1 of 5

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

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Correct Answer: A

Rationale: The correct answer is A: Muffled heart sounds. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This results in muffled heart sounds due to decreased sound transmission through the fluid. Sudden lethargy (
B) may indicate worsening condition but is not specific to cardiac tamponade. Flattened neck veins (
C) are typically seen in hypovolemic shock, not cardiac tamponade. Bradycardia (
D) is not a common finding in cardiac tamponade, as it usually presents with tachycardia due to the heart's compensatory mechanisms.

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