A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Apical pulse rate different than the radial pulse rate

Increase in heart rate by 20% when standing

Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position

Drop in systolic BP more than 10 mm Hg on inspiration

Answer and Explanation

The Correct Answer is D

Choice A reason: An apical pulse rate different than the radial pulse rate is known as a pulse deficit, which can indicate atrial fibrillation or other cardiac arrhythmias, but it is not related to paradoxical blood pressure or constrictive pericarditis.

Choice B reason: An increase in heart rate by 20% when standing is indicative of orthostatic hypotension, not paradoxical blood pressure. This condition involves a drop in blood pressure upon standing, leading to a compensatory increase in heart rate.

Choice C reason: A drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position is another indicator of orthostatic hypotension, not paradoxical blood pressure.

Choice D reason: The correct answer is d because a drop in systolic BP of more than 10 mm Hg on inspiration, known as pulsus paradoxus, is a characteristic finding in constrictive pericarditis. This occurs due to the impaired filling of the heart during inspiration, leading to a significant drop in systolic blood pressure.

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Correct Answer is C

Explanation

Choice A reason: Lactulose is a laxative used to treat constipation and hepatic encephalopathy by reducing blood ammonia levels, but it is not effective in lowering serum potassium levels. Therefore, it would not be the appropriate medication for treating hyperkalemia.

Choice B reason: Triamterene is a potassium-sparing diuretic, which means it helps the body retain potassium. Administering Triamterene in a client with high potassium levels (hyperkalemia) would exacerbate the condition rather than improve it. Hence, it is not a suitable choice for this scenario.

Choice C reason: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by binding to potassium in the intestines and facilitating its removal from the body through feces. It effectively reduces serum potassium levels, making it the appropriate medication for a client with hyperkalemia.

Choice D reason: Acetylcysteine is used primarily as a mucolytic agent to break down mucus in the airways or as an antidote for acetaminophen (paracetamol) overdose. It does not have any effect on serum potassium levels and is not suitable for treating hyperkalemia.

A. Insert an indwelling catheter to monitor for sediment in the urine. B. Take the client's temperature once per shift. C. Provide the client with fresh fruit to avoid constipation. D. Limit the number of health care workers entering the room.

Correct Answer is D

Explanation

Choice A reason: Inserting an indwelling catheter can increase the risk of urinary tract infections, which is particularly dangerous for immunosuppressed clients. Monitoring for sediment can be done through less invasive methods.

Choice B reason: Taking the client's temperature once per shift may not be frequent enough. More frequent monitoring is recommended to detect early signs of infection.

Choice C reason: Providing fresh fruit, while beneficial for preventing constipation, can pose an infection risk due to potential contamination. Alternatives like canned or cooked fruits should be considered.

Choice D reason: Limiting the number of health care workers entering the room reduces the risk of introducing infections to the immunosuppressed client. This is a key measure to protect clients with weakened immune systems.

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A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

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