The nurse receives handoff of care report on four clients. Which client should the nurse see first?

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11ecbb05_c968_ed25_b433_7123ea856f58_MD0009_00 Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Cardiac tamponade decreases atrioventricular filling and impairs the heart's ability to contract and eject blood; it is life-threatening without prompt recognition and treatment. Clinical features of cardiac tamponade include hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) (Option C). In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, and tachycardia may be present. (Option A) Palpitations, tachycardia, and irregular pulse are expected findings in atrial fibrillation. Atrial fibrillation is usually a chronic arrhythmia. The heart rate must be controlled, but this is not a priority over tamponade. (Option B) Liver cirrhosis causes portal hypertension and splenomegaly. An enlarged spleen sequestrates platelets, causing thrombocytopenia. Spontaneous bleeding requires further investigation after addressing a client with possible cardiac tamponade. (Option D) Increased white blood cell count in a client with infection may indicate ineffective treatment and/or progression to sepsis, both of which require follow-up. However, this finding is not immediately life-threatening. Educational objective: Cardiac tamponade is a possible complication of acute pericarditis that impairs cardiac output and is life-threatening without immediate intervention. Clinical features of cardiac tamponade include hypotension, muffled heart sounds, and neck vein distension (Beck triad).

The Nurse Receives Handoff of Care Report on Four Clients