A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds.

Which of the following findings should the nurse be most concerned about?

Pulsus paradoxus.

Exudate.

Aneurysm.

Tamponade.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Pulsus paradoxus, an exaggerated decrease in systolic blood pressure during inspiration, can be a sign of several conditions, including pericardial tamponade, constrictive pericarditis, and restrictive cardiomyopathy.
Choice B rationale
Exudate, a fluid with a high protein content that leaks out of blood vessels due to inflammation, is not typically associated with the symptoms described.
Choice C rationale
An aneurysm, a bulge or ballooning in a blood vessel, could potentially cause the symptoms described, but it is not the most concerning finding given the symptoms of edema, hepatomegaly, and muffled heart sounds.
Choice D rationale
Tamponade, a serious condition in which fluid or blood fills the pericardial sac, compressing the heart and preventing it from pumping effectively, could cause the symptoms described and would be the most concerning finding.

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Correct Answer is C

Explanation

Choice A rationale
A Ventricular Septal Defect (VSD) is a hole in the wall separating the two lower chambers of the heart. While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.
Choice B rationale
An Atrioventricular Canal (AVC) defect is a combination of heart problems resulting in a defect in the center of the heart. While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.
Choice C rationale
Tetralogy of Fallot is a congenital heart condition characterized by four anatomical abnormalities of the heart. It is the most common cyanotic heart defect and the most common cause of blue baby syndrome. Cyanosis, which is caused by a lack of oxygen in the blood, is often seen during periods of activity, such as feeding or crying.
Choice D rationale
An Atrial Septal Defect (ASD) is a hole in the wall between the two upper chambers of your heart (atria). While it can cause cyanosis, it’s typically not associated with cyanosis during crying or feeding.

A. Newly admitted patient with a BP of 150/87 mm Hg. B. Patient with left ventricular failure who has a BP of 110/70 mm Hg. C. Postoperative patient with a BP of 116/42 mm Hg. D. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.

Correct Answer is C

Explanation

The patient with a blood pressure of 116/42 mm Hg has a mean arterial pressure (MAP) of approximately 67 mm Hg, which is less than the standard policy of 70 mm Hg. This could indicate inadequate blood flow to the vital organs, necessitating notification of the healthcare provider.

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A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

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Naxlex Comprehensive Predictor Exams

A newborn frequently experiences cyanosis, typically during crying or after feeding. Which cardiac diagnosis is supported by this history?

Correct Answer is C

Explanation

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Correct Answer is C

Explanation

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A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds.

Which of the following findings should the nurse be most concerned about?