Which assessment finding would the nurse expect in a patient diagnosed with acute pericarditis?

Muffled heart sound

Narrow pulse pressure

Pulses paradoxus

Pericardial friction rub

Answer and Explanation

The Correct Answer is D

A. Muffled heart sounds are more commonly associated with pericardial effusion or cardiac tamponade, where fluid accumulation in the pericardial sac muffles the heart sounds. Acute pericarditis, however, typically does not cause muffled heart sounds.
B. Narrow pulse pressure (a small difference between systolic and diastolic blood pressure) is not a typical finding in acute pericarditis. It is more commonly seen in conditions such as cardiac tamponade or severe heart failure.
C. Pulses paradoxus, a significant decrease in systolic blood pressure during inspiration, is more commonly associated with conditions like cardiac tamponade, not acute pericarditis.
D. A pericardial friction rub is a hallmark sign of acute pericarditis. It occurs due to the inflammation of the pericardial layers, which rub against each other, producing a characteristic high-pitched, scratchy sound heard on auscultation.

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Correct Answer is D

Explanation

A. Post-traumatic arthritis can develop after a fracture, but Buck's traction does not directly prevent or treat arthritis. Post-traumatic arthritis is a long-term complication that is managed through other interventions such as physical therapy or joint replacement if necessary.
B. Intra-articular adhesions refer to scar tissue formation inside the joint, which is not the primary focus of Buck's traction. Buck's traction is used to immobilize the limb and reduce muscle spasm, not to address intra-articular issues.
C. Extra-articular adhesions involve the formation of scar tissue outside the joint and are not specifically targeted by Buck's traction. The primary goal of the boot is to reduce muscle spasm and maintain alignment.
D. Muscle spasm is the primary condition that Buck's traction helps decrease. The boot applies a gentle, continuous pull on the limb, which helps to alleviate muscle spasms, reduce pain, and maintain proper alignment while the fracture heals.

A. Epinephrine administration B. Defibrillation C. Amiodarone administration D. Airway management

Correct Answer is B

Explanation

A. Epinephrine administration is important for managing cardiac arrest, but it is not the first priority in the case of ventricular fibrillation. Defibrillation is the most urgent intervention to restore a normal rhythm.
B. Defibrillation is the priority action for a client in ventricular fibrillation. This life-threatening arrhythmia causes the heart to quiver rather than pump effectively, and defibrillation is the only way to restore a normal rhythm. Immediate defibrillation is critical to prevent death.
C. Amiodarone administration may be indicated after defibrillation if the rhythm persists, but defibrillation should be attempted first.
D. Airway management is essential in cardiac arrest, but it is secondary to the need for defibrillation in this case. The priority is to attempt to restore a normal heart rhythm with defibrillation.

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Which assessment finding would the nurse expect in a patient diagnosed with acute pericarditis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a fracture who has a Buck's traction boot in place. The boot helps decrease which condition?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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