When auscultating the breath sounds of a client with pericarditis, the nurse would expect to find which of the following?
Friction rub
Wheezes
Rales
Rhonchi
The Correct Answer is A
A. A friction rub is the characteristic auscultatory finding in pericarditis. It is a high-pitched, scratchy sound heard best at the left lower sternal border and is caused by the inflamed pericardial layers rubbing against each other.
B. Wheezes are continuous, musical sounds usually associated with airway narrowing, such as in asthma or COPD.
C. Rales (crackles) are heard in conditions like pulmonary edema or pneumonia, not pericarditis.
D. Rhonchi are low-pitched, snoring sounds associated with mucus or obstruction in the larger airways.
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Related Questions
Correct Answer is C
Explanation
A. Anaphylactic shock is a life-threatening allergic reaction, but it is less common and less frequently the cause of ICU deaths compared to septic shock.
B. Neurogenic shock results from spinal cord injuries or central nervous system damage and is relatively rare.
C. Septic shock is the most common cause of death in intensive care units in the United States. It results from overwhelming infection and leads to systemic inflammation, vasodilation, and multi-organ dysfunction.
D. Cardiogenic shock occurs due to the heart’s inability to pump effectively, often after a major myocardial infarction, but it is not the leading cause of death in ICUs.
Correct Answer is []
Explanation
Potential Condition: Atrial Fibrillation
The client presents with an irregular, tachycardic rhythm with unclear P waves, which are classic signs of atrial fibrillation (AF). Symptoms such as palpitations, dizziness, and shortness of breath are common with AF, particularly with a rapid ventricular response.
Actions to Take
• Administer an anticoagulant: AF increases the risk of thrombus formation in the atria, which can lead to embolic stroke. Anticoagulation reduces this risk, especially in symptomatic or persistent cases.
• Obtain a 12-lead ECG: This helps confirm the diagnosis, assess the rhythm in detail, and rule out other arrhythmias or ischemic changes that may be present.
Parameters to Monitor
• Manifestations of stroke: Clients with AF are at increased risk for embolic stroke. Neurological status should be closely monitored for signs of confusion, facial droop, weakness, or speech changes.
• PTT/INR: These lab values help assess coagulation status, particularly when anticoagulants such as warfarin or heparin are initiated, to ensure therapeutic levels and avoid bleeding complications.
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