Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective?
Check the electrocardiogram (ECG) for ST segment changes.
Assess for the presence of jugular venous distention (VD).
Monitor for changes in the patient's sedimentation rate.
Assess for the presence of a paradoxical pulse.
The Correct Answer is B
Choice A rationale:
ST segment changes on an ECG are not typically associated with chronic constrictive pericarditis.
Choice B rationale:
Jugular venous distention (JVD) is a common sign of chronic constrictive pericarditis. If JVD is not present, it may indicate that the therapies are effective.
Choice C rationale:
While the sedimentation rate can indicate inflammation, it is not specific to chronic constrictive pericarditis.
Choice D rationale:
The presence of a paradoxical pulse is not typically associated with chronic constrictive pericarditis.
So, the correct answer is B, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.
Choice B rationale:
While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.
Choice C rationale:
Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.
Choice D rationale:
Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.
So, the correct answer is Choice C, after analyzing all choices. .
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Obtaining blood cultures x 3 is anticipated for the client. This is because the adolescent’s symptoms such as fever, shortness of breath, and petechiae could indicate a bacterial infection, possibly endocarditis, which is a risk for individuals with a history of rheumatic fever and cardiac valve damage. Blood cultures would help identify the causative bacteria.
Choice B rationale:
Administering antibiotic therapy is anticipated for the client. The adolescent’s symptoms suggest a possible bacterial infection, which could have been introduced during the recent dental work. Antibiotics would help eliminate the bacteria and prevent further complications.
Choice C rationale:
Obtaining an echocardiogram is anticipated for the client. Given the adolescent’s history of rheumatic fever and cardiac valve damage, and current symptoms like shortness of breath and chest pain, an echocardiogram would help assess the condition of the heart valves and detect any abnormalities.
Choice D rationale:
Restricting dental hygiene is contraindicated for the client. Good oral hygiene is important, especially for individuals with a history of rheumatic fever and cardiac valve damage, as it helps prevent oral infections that could potentially spread to the heart.
Choice E rationale:
Performing a strenuous exercise regimen twice daily is contraindicated for the client. The adolescent is currently experiencing symptoms like shortness of breath and chest pain, which could be exacerbated by strenuous exercise. It’s important to avoid overexertion until the adolescent’s condition stabilizes.
So, the correct answer is, after analyzing all choices, Choices A, B, and C are anticipated for the client, while Choices D and E are contraindicated. .
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