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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Providing a diet high in protein is not appropriate during the oliguric phase of acute kidney injury, as it can increase the workload on the kidneys and worsen kidney function. Protein intake should be carefully managed based on the client's condition.

Choice B reason: Ibuprofen is contraindicated in clients with acute kidney injury because it can further impair kidney function. Pain management should be approached with alternative medications that do not have nephrotoxic effects.

Choice C reason: The correct answer is c because monitoring intake and output hourly is crucial in managing acute kidney injury. Accurate measurement of fluid balance helps guide treatment decisions and prevent complications such as fluid overload or dehydration.

Choice D reason: Encouraging the client to consume at least 2 L of fluid daily is not appropriate in the oliguric phase, as the kidneys' ability to excrete fluids is impaired. Fluid intake should be carefully restricted and monitored to avoid fluid overload.

A. Refusing to look at the dressing or surgical incision. B. Requesting pain medication every 3 hr. C. Asking questions about the information on the postoperative care pamphlet. D. Performing arm exercises once or twice each day.

Correct Answer is A

Explanation

Choice A reason: The correct answer is a because refusing to look at the dressing or surgical incision can indicate that the client is having difficulty accepting the loss of her breast. This behavior may suggest that the client is struggling with body image issues, grief, or denial about the changes to her body.

Choice B reason: Requesting pain medication every 3 hours is a common postoperative behavior to manage pain and does not necessarily indicate difficulty adjusting to the loss of a breast. Pain management is a normal part of recovery.

Choice C reason: Asking questions about the information on the postoperative care pamphlet demonstrates an interest in understanding and managing her care. This behavior indicates that the client is engaged in her recovery process, rather than struggling to adjust.

Choice D reason: Performing arm exercises once or twice each day shows that the client is following postoperative care instructions and is actively participating in her rehabilitation. This behavior does not suggest difficulty adjusting to the loss of her breast.

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A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following client behaviors should alert the nurse that the client is having difficulty adjusting to the loss of her breast?

Correct Answer is A

Explanation

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A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

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