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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A BMI of 20 falls within the healthy weight range for adults, indicating that the client's weight is appropriate for his height.

B. A BMI of 20 is not indicative of malnutrition. Malnutrition is typically associated with lower BMIs.

C. A BMI of 20 is not within the overweight range, as overweight is typically defined as a BMI between 25 and 29.9.

D. A BMI of 20 is not within the obesity range, as obesity is typically defined as a BMI of 30 or higher.

A. "My stoma size will stay the same, even after it has healed." B. "My stoma will drain liquid fluid continuously." C. "I will change my pouch system every 2 weeks." D. "I will ensure that my medications are enteric coated."

Correct Answer is B

Explanation

A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.

Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.

B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.

C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.

D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.

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A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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