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 B

Explanation

Choice A reason: Limiting fluid intake is not an appropriate intervention for labyrinthitis. Adequate hydration is important for overall health and should be maintained.

Choice B reason: The correct answer is b because labyrinthitis can affect the vestibular system, leading to dizziness and vertigo. Monitoring the client’s cardinal fields of vision helps assess for nystagmus, which is a common symptom of vestibular disorders.

Choice C reason: Encouraging ambulation is not advisable for clients with labyrinthitis, as it can increase the risk of falls and injury due to dizziness and imbalance.

Choice D reason: Ensuring the room is brightly lit is not necessary for the management of labyrinthitis and may not provide any therapeutic benefit.

A. Feed the client soft foods for several days. B. Position the client on the affected side to rest. C. The client should remain in bed for 3 days. D. The client should wear dark glasses while outdoors.

Correct Answer is D

Explanation

Choice A reason: Feeding the client soft foods is not necessary after cataract surgery. Cataract surgery does not affect the client's ability to eat regular foods, and a normal diet can be resumed unless otherwise instructed by the healthcare provider.

Choice B reason: Positioning the client on the affected side is contraindicated after cataract surgery because it can increase pressure on the eye and disrupt the healing process. Clients are usually advised to avoid sleeping on the side of the operated eye to prevent complications.

Choice C reason: It is not necessary for the client to remain in bed for 3 days following cataract surgery. Clients are encouraged to resume normal activities as tolerated, but they should avoid strenuous activities and heavy lifting to prevent increased intraocular pressure.

Choice D reason: The correct answer is d because wearing dark glasses while outdoors helps protect the eyes from bright light and UV rays, which can cause discomfort and harm the healing eye after cataract surgery.

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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

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