While admitting a patient with pericarditis, what manifestations of this disorder should the nurse assess for?
Prolonged PR intervals.
Clubbing of the fingers.
Widened pulse pressure.
Pulsus paradoxus.
The Correct Answer is D
Choice A rationale
Prolonged PR intervals occur with first-degree AV block, not typically with pericarditis.
Choice B rationale
Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found in endocarditis, congenital defects, and/or prolonged oxygen deficiency. It is not a typical manifestation of pericarditis.
Choice C rationale
Widened pulse pressure occurs with valvular heart disease, not typically with pericarditis.
Choice D rationale
Pulsus paradoxus is a sign of cardiac tamponade, a serious complication of pericarditis. As the compression of the heart increases, decreased left atrial filling decreases cardiac output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.
Correct Answer is D
Explanation
Choice A rationale
Sinus tachycardia at a rate of 110 beats/min is a normal response to exercise. During a stress test, the heart rate will naturally increase as the body’s demand for oxygen increases. A heart rate of 110 beats/min is within the expected range during moderate exercise.
Choice B rationale
An increase in blood pressure from 134/68 to 150/80 mm Hg is a normal response to exercise. During a stress test, blood pressure will naturally rise as the heart works harder to pump blood to the muscles. This increase is within the expected range during moderate exercise.
Choice C rationale
Feeling tired during a stress test on a treadmill is a normal response to exercise. Fatigue can occur as the body’s energy stores are used up during physical activity. However, if the patient reports extreme fatigue or other symptoms such as chest pain or shortness of breath, it may indicate a problem.
Choice D rationale
Inversion of T waves on the electrocardiogram during a stress test is a sign of myocardial ischemia, a condition in which the heart muscle is not getting enough oxygen. This could indicate the presence of significant coronary artery disease and is a finding that would necessitate immediate action.
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