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

A.

Muffled heart sound

B.

Narrow pulse pressure

C.

Pulses paradoxus

D.

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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Related Questions

Correct Answer is ["A","C","D","E"]

Explanation

A. Assess for neck vein distention: Cushing's syndrome is associated with fluid retention and increased blood volume, which can lead to neck vein distention.
B. Monitor for postural hypotension: This is typically not a concern in Cushing's syndrome. In fact, clients with Cushing's syndrome often experience elevated blood pressure due to increased fluid volume and sodium retention.
C. Assess blood glucose level: Cushing's syndrome often causes hyperglycemia due to excess cortisol, which can impair insulin action and increase blood glucose levels.
D. Weigh the client daily: Weight gain, particularly in the face, abdomen, and upper back, is a common symptom of Cushing's syndrome due to fluid retention and fat redistribution. Monitoring weight is important for tracking fluid retention.
E. Monitor for an irregular heart rate: Cushing's syndrome can lead to electrolyte imbalances, such as hypokalemia, which can affect heart rhythm, leading to arrhythmias.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Improved:

  • Blood Pressure: Improved from 148/88 mmHg to 130/74 mmHg.
  • Jugular Venous Distention: Improved, now absent.
  • Lung sounds: Improved, now clear bilaterally.
  • Serum Potassium: Improved from 5.7 mEq/L to 4.4 mEq/L.
  • Weight: Improved from 102.7 kg (226 lb.) to 100 kg (220 lb.).

No change:

  • Dyspnea: No change, still observed on exertion.
  • Oxygen saturation: No change, remains at 95% on room air.

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