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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Feeding the client soft foods is not necessary after cataract surgery. Cataract surgery does not affect the client's ability to eat regular foods, and a normal diet can be resumed unless otherwise instructed by the healthcare provider.
Choice B reason: Positioning the client on the affected side is contraindicated after cataract surgery because it can increase pressure on the eye and disrupt the healing process. Clients are usually advised to avoid sleeping on the side of the operated eye to prevent complications.
Choice C reason: It is not necessary for the client to remain in bed for 3 days following cataract surgery. Clients are encouraged to resume normal activities as tolerated, but they should avoid strenuous activities and heavy lifting to prevent increased intraocular pressure.
Choice D reason: The correct answer is d because wearing dark glasses while outdoors helps protect the eyes from bright light and UV rays, which can cause discomfort and harm the healing eye after cataract surgery.
Correct Answer is D
Explanation
Choice A reason: Telling the partner to call the nurse to push the button is not appropriate. PCA is designed to allow the client to self-administer pain medication based on their own perception of pain. Only the client should press the button to avoid the risk of over-sedation and respiratory depression.
Choice B reason: Encouraging the partner to press the button while the client is asleep can lead to over-medication and serious complications such as respiratory depression.
Choice C reason: Asking the partner why they think more medication is needed when the client is asleep does not address the underlying issue of inappropriate use of the PCA pump.
Choice D reason: The correct answer is d because the client should be the one to decide when more medication is needed. This ensures that the client receives the appropriate amount of pain relief based on their individual needs and prevents the risk of over-sedation.
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