A nurse is caring for a client who has pericarditis. Which of the following interventions should the nurse implement?

Position the client with the head of the bed elevated to a 15° angle.

Check the client for jugular venous flattening.

Administer an anticoagulant medication to the client.

Assess the client for a paradoxical blood pressure.

Answer and Explanation

The Correct Answer is D

A. Position the client with the head of the bed elevated to a 15° angle: Clients with pericarditis typically experience relief when sitting up and leaning forward, as this reduces pressure on the inflamed pericardium. A 15° elevation is too low to provide significant relief.

B. Check the client for jugular venous flattening: Pericarditis, especially when complicated by cardiac tamponade, leads to jugular venous distension rather than flattening due to impaired venous return to the heart.

C. Administer an anticoagulant medication to the client: Anticoagulants are not routinely used in pericarditis because they may increase the risk of hemorrhagic pericardial effusion, particularly if pericarditis is due to an inflammatory or infectious cause.

D. Assess the client for a paradoxical blood pressure: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, is a key sign of cardiac tamponade, a life-threatening complication of pericarditis. Monitoring for this helps in early detection and management.

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Correct Answer is D

Explanation

A. Discontinue opioids before trying nonpharmacological methods of pain relief: Nonpharmacological interventions can be used alongside opioids to enhance pain relief. Abruptly discontinuing opioids can lead to withdrawal symptoms and inadequate pain control.

B. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus: While heat and cold therapy can provide temporary relief, their effects typically last for a short duration, usually around 15 to 30 minutes after removal.

C. Use imagery with clients who have difficulty with focus and concentration: Guided imagery requires cognitive focus and the ability to concentrate. Clients with impaired attention may struggle to benefit from this technique.

D. Distraction changes the client's perception of pain, but it does not affect the cause: Distraction techniques, such as music or conversation, help shift the client's attention away from pain, altering perception but not addressing the underlying pathology.

A. I have a sore that won't get better on my right foot." B. Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot C. draining small amount of purulent drainage D. frequent urination E. increased thirst F. recent 4.5 kg (10 lb) weight loss without trying G. Temperature 38.3° C (100.9°F) H. Heart rate 104/min I. Blood pressure 98/74 mm Hg J. Blood glucose 250 mg/dL (74 to 106 mg/dL)

Correct Answer is ["C","D","E","F","G","H","I","J"]

Explanation

Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
BMI 27: Slightly overweight but not directly contributing to the acute condition.

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A nurse is caring for a client who has pericarditis. Which of the following interventions should the nurse implement?

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