NCLEX-RNPhysiological AdaptationMedium
A client presents with hypotension, jugular venous distention, and muffled heart sounds after a motor vehicle collision. Which diagnosis should the nurse suspect?
- ACardiac tamponade
- BPulmonary embolism
- CTension pneumothorax
- DMyocardial infarction
Show answer & explanationAnswer & explanation
Correct answer: A. Cardiac tamponade
Beck's triad—hypotension, jugular venous distention, and muffled heart sounds—is classic for cardiac tamponade, in which fluid accumulates in the pericardial sac and compresses the heart, impairing cardiac output.
Why the other options are wrong
- B. Pulmonary embolism presents with sudden dyspnea and pleuritic chest pain, not muffled heart sounds.
- C. Tension pneumothorax presents with tracheal deviation, absent breath sounds, and hyperresonance, not muffled heart sounds.
- D. MI typically presents with chest pain and ECG changes, not this triad.
Cardiac Tamponade (Beck's Triad)
Pericardial fluid accumulation compresses the heart, causing hypotension, JVD, and muffled heart sounds.
- Beck's triad: hypotension, JVD, muffled heart sounds
- Pulsus paradoxus (>10 mmHg drop in SBP on inspiration) supports diagnosis
- Emergency treatment is pericardiocentesis
- Common after trauma, cardiac surgery, or pericarditis
Memory trick: Beck's Triad: BP down, veins up, sounds muffled