Which assessment finding would the nurse expect in a patient diagnosed with acute pericarditis?
Muffled heart sound
Narrow pulse pressure
Pulses paradoxus
Pericardial friction rub
The Correct Answer is D
A. Muffled heart sounds are more commonly associated with pericardial effusion or cardiac tamponade, where fluid accumulation in the pericardial sac muffles the heart sounds. Acute pericarditis, however, typically does not cause muffled heart sounds.
B. Narrow pulse pressure (a small difference between systolic and diastolic blood pressure) is not a typical finding in acute pericarditis. It is more commonly seen in conditions such as cardiac tamponade or severe heart failure.
C. Pulses paradoxus, a significant decrease in systolic blood pressure during inspiration, is more commonly associated with conditions like cardiac tamponade, not acute pericarditis.
D. A pericardial friction rub is a hallmark sign of acute pericarditis. It occurs due to the inflammation of the pericardial layers, which rub against each other, producing a characteristic high-pitched, scratchy sound heard on auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While bile and pancreatic enzymes play a role in digestion, dumping syndrome is not related to an increase in their secretion.
B. Dumping syndrome is not caused by an inability to digest high-fat foods, but rather by the rapid passage of undigested food into the small intestine, which can cause symptoms like nausea, dizziness, and diarrhea.
C. Dumping syndrome occurs when food, especially sugar, moves too quickly from the stomach into the small intestine, overwhelming the digestive system. This leads to symptoms like abdominal cramping, dizziness, and diarrhea.
D. Dumping syndrome is not related to insulin secretion; it is more about the rapid emptying of food into the small intestine.
Correct Answer is D
Explanation
A. Elevating the feet can help reduce swelling and promote venous return, which is beneficial in preventing VTE.
B. Flexing the ankles (e.g., through ankle pumps) is an effective way to promote circulation and reduce the risk of VTE.
C. Ambulating soon after surgery is encouraged as it helps improve circulation and reduces the risk of blood clots.
D. Massaging the legs is unsafe because it can dislodge a clot if one is present, leading to a potential embolism. It is important to avoid deep pressure on the legs in clients at risk for VTE.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.