A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Dependent edema

Pericardial friction rub

Paradoxical pulse

Substernal chest pain

Answer and Explanation

The Correct Answer is D

A. Dependent edema may be present in pericarditis but is not typically the priority finding unless it indicates worsening heart failure.

B. Pericardial friction rub is a classic finding in pericarditis but is not the priority unless it indicates cardiac tamponade, which is a medical emergency.

C. Paradoxical pulse may occur in pericarditis but is not necessarily the priority finding unless it is severe and indicative of cardiac tamponade.

D. Substernal chest pain is the priority finding in pericarditis as it indicates inflammation of the pericardium, which can lead to complications such as myocardial infarction or cardiac

tamponade. Prompt intervention is necessary to alleviate pain and prevent complications.

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Correct Answer is C

Explanation

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

A. Brush teeth immediately after eating. B. Lay down for 30 min after meals. C. Drink 12 oz of water with each meal. D. Eat a dry carbohydrate before getting out of bed.

Correct Answer is D

Explanation

A. Brushing teeth immediately after eating may exacerbate nausea, especially if the client is experiencing pregnancy-related nausea and vomiting.

B. Laying down for 30 minutes after meals may worsen nausea and reflux symptoms.

C. Drinking 12 oz of water with each meal may contribute to feelings of fullness and exacerbate nausea and vomiting.

D. Eating a dry carbohydrate before getting out of bed, such as crackers or dry toast, can help alleviate nausea and vomiting associated with pregnancy by providing a bland, easily digestible source of energy before the client starts moving in the morning.

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A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Nursing Test Bank

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