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: While early CPR is crucial, the AED should be attached as soon as it is available to analyze the heart rhythm and provide a shock if needed. Delaying the use of the AED can reduce the chances of successful resuscitation.

Choice B reason: In adults, the carotid pulse is typically checked, not the brachial pulse. The brachial pulse is more commonly assessed in infants.

Choice C reason: The correct answer is c because providing chest compressions at a rate of 100-120 compressions per minute is the recommended rate for effective CPR. High-quality chest compressions are essential for maintaining circulation during cardiac arrest.

Choice D reason: The recommended ratio of chest compressions to rescue breaths is 30:2, not 50:2. Performing 50 compressions before providing rescue breaths is not aligned with current CPR guidelines.

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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