A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?
Allow the client to lie in bed with the lights dim.
Provide a neck rub, especially on the left side.
Sit the client up with a pillow to lean forward on.
Apply an ice pack to the client's chest.
The Correct Answer is C
A. Allow the client to lie in bed with the lights dim: While a dimly lit environment may reduce general stress, it does not specifically relieve the chest pain associated with acute pericarditis. Comfort measures must target the positional nature of pericardial pain.
B. Provide a neck rub, especially on the left side: A neck rub may offer mild relaxation, but it does not address the underlying pericardial inflammation causing the substernal, radiating pain. This intervention is unlikely to significantly reduce discomfort.
C. Sit the client up with a pillow to lean forward on: Pain from acute pericarditis is often relieved when the client leans forward, as this reduces pressure on the inflamed pericardial surfaces. Sitting upright and leaning forward helps decrease friction between the pericardium and the heart, providing nonpharmacologic relief.
D. Apply an ice pack to the client's chest: Cold application may provide minimal relief for superficial musculoskeletal pain but is generally ineffective for the deep, inflammatory chest pain of pericarditis. It does not reduce pericardial friction or inflammation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Allow the client to lie in bed with the lights dim: While a dimly lit environment may reduce general stress, it does not specifically relieve the chest pain associated with acute pericarditis. Comfort measures must target the positional nature of pericardial pain.
B. Provide a neck rub, especially on the left side: A neck rub may offer mild relaxation, but it does not address the underlying pericardial inflammation causing the substernal, radiating pain. This intervention is unlikely to significantly reduce discomfort.
C. Sit the client up with a pillow to lean forward on: Pain from acute pericarditis is often relieved when the client leans forward, as this reduces pressure on the inflamed pericardial surfaces. Sitting upright and leaning forward helps decrease friction between the pericardium and the heart, providing nonpharmacologic relief.
D. Apply an ice pack to the client's chest: Cold application may provide minimal relief for superficial musculoskeletal pain but is generally ineffective for the deep, inflammatory chest pain of pericarditis. It does not reduce pericardial friction or inflammation.
Correct Answer is A
Explanation
A. Pericardial friction rub: Pericarditis is inflammation of the pericardial sac. The classic auscultatory finding is a high-pitched, scratchy pericardial friction rub heard best at the left lower sternal border. It is caused by the inflamed pericardial layers rubbing against each other and is a hallmark sign of pericarditis.
B. Mitral murmur: A mitral murmur is associated with mitral valve disorders such as mitral stenosis or mitral regurgitation, not inflammation of the pericardium.
C. Pleural friction rub: A pleural friction rub is heard with pleuritis and is related to lung and pleural inflammation. It is respiratory in origin and changes with breathing, unlike a pericardial friction rub.
D. S3 or S4: An S3 is commonly associated with heart failure, and an S4 is often linked to decreased ventricular compliance, such as in hypertension. These are not characteristic findings of acute pericarditis.
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