A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
Dependent edema
Pericardial friction rub
Paradoxical pulse
Substernal chest pain
The Correct Answer is C
A. Dependent edema can occur with pericarditis but does not indicate an immediate life-threatening complication.
B. A pericardial friction rub is a common finding in pericarditis and helps confirm the diagnosis but is not the priority.
C. A paradoxical pulse (an exaggerated decrease in systolic blood pressure during inspiration) is a sign of cardiac tamponade, a life-threatening complication of pericarditis, and requires immediate intervention.
D. Substernal chest pain is expected with pericarditis and is usually relieved by sitting up and leaning forward, but it is not the most urgent concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Asymmetric lesions with variegated (multiple) colors are characteristic features of melanoma, a type of skin cancer. Asymmetry means one half of the lesion does not match the other half in size, shape, or color.
B. Scaly and red lesions may indicate other skin conditions such as eczema or psoriasis but are not specific to skin cancer.
C. Brown lesions with a wart-like texture may indicate seborrheic keratosis, a benign skin growth, rather than skin cancer.
D. Firm and rubbery lesions may indicate benign skin tumors such as fibromas or lipomas, rather than skin cancer.
Correct Answer is A
Explanation
A.
A. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.
B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.
C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.
D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.
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