A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?
Apical pulse rate different than the radial pulse rate
Increase in heart rate by 20% when standing
Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position
Drop in systolic BP more than 10 mm Hg on inspiration
The Correct Answer is D
Choice A reason: An apical pulse rate different than the radial pulse rate is known as a pulse deficit, which can indicate atrial fibrillation or other cardiac arrhythmias, but it is not related to paradoxical blood pressure or constrictive pericarditis.
Choice B reason: An increase in heart rate by 20% when standing is indicative of orthostatic hypotension, not paradoxical blood pressure. This condition involves a drop in blood pressure upon standing, leading to a compensatory increase in heart rate.
Choice C reason: A drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position is another indicator of orthostatic hypotension, not paradoxical blood pressure.
Choice D reason: The correct answer is d because a drop in systolic BP of more than 10 mm Hg on inspiration, known as pulsus paradoxus, is a characteristic finding in constrictive pericarditis. This occurs due to the impaired filling of the heart during inspiration, leading to a significant drop in systolic blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Osteoarthritis is a degenerative joint disease and is not associated with SIADH. It does not typically affect the body's regulation of antidiuretic hormone (ADH) or fluid balance.
Choice B reason: Lung cancer, particularly small cell lung cancer, is a common cause of SIADH. Tumor cells can produce and secrete ADH, leading to inappropriate water retention and hyponatremia. Therefore, asking about lung cancer history is important in the assessment.
Choice C reason: The correct answer is c because liver cirrhosis can lead to secondary conditions that may affect fluid balance and ADH secretion. Although not a direct cause of SIADH, liver dysfunction can complicate the clinical picture and contribute to fluid retention issues.
Choice D reason: Dyspepsia, or indigestion, is not related to SIADH and does not typically impact ADH regulation. It is a gastrointestinal issue that does not affect fluid balance.
Choice E reason: The correct answer is e because seizures can be associated with conditions that trigger SIADH. Neurological disorders, including brain injuries and infections, can lead to the inappropriate release of ADH, resulting in fluid retention and hyponatremia.
Correct Answer is D
Explanation
Choice A reason: A dry raised rash is not a typical finding in scleroderma. Scleroderma primarily affects the skin and connective tissues, leading to hardening and tightening of the skin.
Choice B reason: Excessive salivation is not associated with scleroderma. Clients with scleroderma may experience dry mouth (xerostomia) instead.
Choice C reason: Periorbital edema is not a characteristic feature of scleroderma. Scleroderma involves systemic sclerosis that affects the skin, blood vessels, and internal organs.
Choice D reason: The correct answer is d because hardened skin is a hallmark of scleroderma. This autoimmune disease causes the skin to become thickened, tight, and stiff due to excessive collagen deposition.
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