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Which assessment finding would pose the greatest concern to the emergency department nurse if a patient presents with a suspected aortic dissection?

A. Pulse 96 beats/min, creatinine level 1.3 mg/dL, low urine output
B. Respirations 24, lower extremity weakness, tingling in fingers
C. BP 86/64, positive jugular vein distention, muffled heart sounds
D. Temperature 99.1 degrees Fahrenheit, decreased bowel sounds, abdominal pain

Answer :

Final answer:

The most concerning findings for a patient with suspected aortic dissection are low blood pressure (BP 86/64), positive jugular vein distention, and muffled heart sounds. These symptoms suggest a possible cardiac tamponade or severe hypovolemia, which are critical conditions requiring immediate attention. Other symptoms, while notable, are less urgent in this context.


Explanation:

Assessment Findings in Aortic Dissection

When a patient presents with a suspected aortic dissection, emergency department nurses must prioritize assessment findings in order to determine the severity of the condition. Among the findings listed, the following point requires the greatest concern:

  • BP 86/64, positive jugular vein distention, muffled heart sounds

This combination of symptoms indicates potential cardiac tamponade or significant blood loss, which can occur if the dissection affects the aorta or adjacent structures. Low blood pressure (BP) of 86/64 mmHg suggests shock, which can be life-threatening, while positive jugular vein distention reflects increased central venous pressure, and muffled heart sounds signify fluid around the heart, limiting its ability to pump effectively.

Other findings, although concerning, do not present as immediate threats. For example:

  1. Pulse of 96 beats/min and creatinine level of 1.3 mg/dL shows some distress but is not the most critical.
  2. Respirations at 24 indicate mild distress, and lower extremity weakness can indicate neurological involvement but is secondary.
  3. Temperature 99.1°F and decreased bowel sounds could suggest other issues but are less urgent in a scenario of a possible life-threatening dissection.

In summary, the findings of hypotension, jugular vein distention, and muffled heart sounds should prompt immediate intervention and further investigation for potential complications such as cardiac tamponade.


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