A nurse is assessing a client suspected of having cardiac tamponade. Which of the following findings indicates the presence of pulsus paradoxus?
A decrease in systolic blood pressure greater than 10 mm Hg during inspiration
A decrease in heart rate greater than 10/min when lying down
An increase in diastolic blood pressure greater than 10 mm Hg during inspiration
An increase in heart rate greater than 20/min when standing
The Correct Answer is A
A. A decrease in systolic blood pressure greater than 10 mm Hg during inspiration: Pulsus paradoxus is an exaggerated decrease in systolic blood pressure during inspiration. Normally, there is a slight decrease in systolic blood pressure during inspiration due to increased intrathoracic pressure and decreased venous return to the heart. However, in conditions such as cardiac tamponade or severe asthma exacerbations, the decrease in systolic blood pressure during inspiration is more pronounced (>10 mm Hg), indicating impaired cardiac output and decreased left ventricular filling during inspiration.
B. A decrease in heart rate greater than 10/min when lying down: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when lying down.
C. An increase in diastolic blood pressure greater than 10 mm Hg during inspiration: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus is characterized by an exaggerated decrease in systolic blood pressure during inspiration, not changes in diastolic blood pressure.
D. An increase in heart rate greater than 20/min when standing: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when standing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Restlessness: Restlessness is a common behavioral manifestation in clients with Alzheimer's disease. It can be caused by various factors, including confusion, agitation, discomfort, or unmet needs. Restlessness may manifest as pacing, fidgeting, or difficulty sitting still.
B. Aggression: Aggression, including verbal or physical aggression, is a behavioral manifestation that can occur in clients with Alzheimer's disease. Aggression may result from frustration, confusion, fear, or other underlying factors. It can present challenges for both the individual with Alzheimer's and their caregivers.
C. Depression: Depression is a mood disorder that can occur in individuals with Alzheimer's disease. Symptoms of depression may include persistent sadness, feelings of hopelessness, social withdrawal, and loss of interest in previously enjoyed activities. Depression can exacerbate cognitive decline and functional impairment in individuals with Alzheimer's.
D. Hyperactivity: Hyperactivity, characterized by excessive or restless activity, can occur in some individuals with Alzheimer's disease. Hyperactivity may be a manifestation of agitation, anxiety, or other underlying factors. It can present challenges for caregivers and may require interventions to manage.
E. Lethargy: Lethargy, or extreme fatigue and lack of energy, can also occur in individuals with Alzheimer's disease. Lethargy may result from physical and cognitive decline, medication side effects, depression, or other medical conditions. It can contribute to decreased engagement in activities and worsening of cognitive function.
Correct Answer is D
Explanation
A. "Vision changes occur when blood vessels leak fluid or blood under a portion of the retina": This statement describes a symptom of diabetic retinopathy, not open-angle glaucoma. In open-angle glaucoma, vision changes primarily result from increased intraocular pressure (IOP) due to impaired drainage of aqueous humor, not leakage of fluid or blood under the retina.
B. "Vision changes occur when the cloudy lens alters the passage of light through the eye": This statement describes a symptom of cataracts, not open-angle glaucoma. Cataracts involve clouding of the lens inside the eye, which affects the passage of light and leads to visual disturbances. Open-angle glaucoma, however, primarily affects the optic nerve and visual field due to increased intraocular pressure.
C. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye": This statement describes a symptom of retinal detachment, not open-angle glaucoma. Retinal detachment occurs when the retina detaches from the underlying layers of the eye, leading to vision changes and potentially vision loss. Open-angle glaucoma, on the other hand, primarily involves increased intraocular pressure and optic nerve damage.
D. "Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor": This statement is accurate. In open-angle glaucoma, vision changes occur due to increased intraocular pressure resulting from inadequate drainage of aqueous humor from the eye. This increased pressure can lead to damage of the optic nerve, resulting in peripheral vision loss and potentially blindness if left untreated.
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