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 B
Explanation
Choice A reason: Fresh fruits and vegetables can harbor bacteria and other pathogens that pose a significant infection risk to neutropenic clients. It's advisable to avoid these foods unless they are cooked or properly washed and peeled.
Choice B reason: Avoiding crowded places is essential for neutropenic clients because their immune system is weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to infectious agents.
Choice C reason: Participating in gardening is not recommended as it exposes neutropenic clients to soil bacteria and fungi, which can cause infections. Activities should be chosen carefully to minimize infection risk.
Choice D reason: Taking temperature weekly is not adequate for neutropenic clients. Daily temperature monitoring is important for early detection of infections, which can progress rapidly in immunocompromised individuals.
Correct Answer is B
Explanation
Choice A reason: Actinic keratosis is a rough, scaly patch on the skin caused by long-term sun exposure. It is usually not purplish-brown and is more common in fair-skinned individuals. These lesions are considered pre-cancerous and can develop into squamous cell carcinoma if left untreated. The description of purplish-brown lesions in the context of an AIDS diagnosis is more indicative of Kaposi's sarcoma.
Choice B reason: Kaposi's sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. It often presents as purplish-brown, red, or bluish lesions on the skin or mucous membranes and is commonly associated with AIDS. The multiple, widespread nature of the lesions described aligns with the typical presentation of Kaposi's sarcoma, making it the most likely diagnosis in this scenario.
Choice C reason: Actinic dermatitis, also known as photodermatitis, is an inflammatory reaction of the skin to sunlight. It does not typically present as purplish-brown lesions. This condition manifests as redness, swelling, and possibly blistering in sun-exposed areas. The description given is not consistent with actinic dermatitis and points more towards Kaposi's sarcoma in an AIDS client.
Choice D reason: Basal cell carcinoma does not usually present with multiple, widespread purplish-brown lesions. It is typically a localized lesion that appears as a pearly or waxy bump. The description of multiple, widespread lesions is more characteristic of Kaposi's sarcoma in clients with AIDS, making basal cell carcinoma an unlikely diagnosis in this context.
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