The nurse is reviewing the electrocardiogram (ECG) of a client admitted for acute pericarditis. Which ECG change does the nurse anticipate?
Peaked T waves.
ST Elevation.
Wide QRS complexes.
Sinus Arrhythmia.
The Correct Answer is B
A. Peaked T waves: Peaked T waves are most commonly associated with hyperkalemia and are not a characteristic finding in acute pericarditis. Relying on this sign could lead to misinterpretation of the underlying cardiac condition.
B. ST Elevation: Acute pericarditis typically causes diffuse, concave upward ST-segment elevations across multiple ECG leads without reciprocal ST depression. This reflects inflammation of the pericardial layers affecting the myocardial electrical activity. ST elevation in this context is a hallmark indicator of pericardial inflammation rather than myocardial infarction.
C. Wide QRS complexes: Widened QRS complexes suggest bundle branch block or ventricular conduction delay, which are not typical findings in pericarditis. QRS morphology usually remains normal in pericardial inflammation unless concurrent conduction system disease exists.
D. Sinus Arrhythmia: Sinus arrhythmia represents a normal variation in heart rate during the respiratory cycle. It is not specifically associated with pericardial inflammation and would not serve as a diagnostic ECG finding in acute pericarditis.
Nursing Test Bank
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 D
Explanation
A. Discontinue the nitroglycerin drip: Stopping nitroglycerin abruptly can worsen myocardial ischemia by removing vasodilatory support. Discontinuation is not indicated for new-onset chest pain; rather, the infusion is typically adjusted to relieve angina while monitoring hemodynamic status.
B. Maintain the nitroglycerin drip at the same rate: Keeping the infusion at the current rate may be insufficient if the client is experiencing new chest pain. The purpose of IV nitroglycerin is to provide continuous antianginal effect, and dose adjustments are often necessary to address breakthrough symptoms.
C. Administer sublingual nitroglycerin: Sublingual nitroglycerin provides rapid relief of acute angina; however, for a client already on an IV infusion, the priority action is usually to titrate the IV rate to achieve continuous pain control while maintaining safe blood pressure. Sublingual administration may be considered if the infusion cannot be adjusted promptly.
D. Titrate the nitroglycerin drip dose up: Increasing the IV nitroglycerin rate is the appropriate intervention for breakthrough chest pain when vital signs are stable. Titration allows the nurse to optimize coronary vasodilation, reduce myocardial oxygen demand, and relieve angina, while continuously monitoring blood pressure and heart rate to prevent hypotension.
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