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. "Reporting the incident to Adult Protective Services" is crucial when there are signs of elder abuse or neglect. This action ensures that appropriate interventions are initiated to protect the client.
B. "Interviewing the client with his adult child present" may not allow the client to speak freely, especially if the adult child is the perpetrator or involved in the abuse. Confidentiality and safety are essential considerations.
C. "Telling the client he must answer every assessment question" can be intimidating and may not facilitate open communication, especially in situations involving abuse.
D. "Advising the client to consult a social worker" may be appropriate after reporting the incident to Adult Protective Services, but it is not the initial action to take when abuse is suspected. Reporting to authorities is the priority to ensure the client's safety.
Correct Answer is C
Explanation
A. Alendronate should be taken on an empty stomach, preferably in the morning, and the client should wait at least 30 minutes before eating or drinking anything other than water.
B. Alendronate should be taken in the morning, not at bedtime, to reduce the risk of esophageal irritation and ensure proper absorption.
C. Taking alendronate with 8 ounces of water helps facilitate proper absorption and reduces the risk of esophageal irritation.
D. Increasing caffeine intake while taking alendronate is not recommended, as caffeine can interfere with calcium absorption and potentially worsen osteoporosis.
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