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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Administering antibiotics is the priority intervention for acute osteomyelitis. The infection needs to be treated promptly to prevent further bone destruction and complications. Antibiotic therapy is essential in managing the infection and promoting healing.
B. Providing antipyretic therapy is important for managing fever, but it is secondary to treating the infection itself with antibiotics.
C. Increasing protein intake is beneficial for overall healing, but it is not the priority in the acute phase of osteomyelitis. The immediate concern is treating the infection.
D. Teaching relaxation breathing may help manage pain, but it does not address the underlying infection. The priority is to administer antibiotics to treat the osteomyelitis.

A. Place the child on a low-sodium diet. B. Teach the parents about cortisol replacement therapy. C. Discuss the manifestations of hyperglycemia with the parents. D. Monitor the child for fluid volume excess.

Correct Answer is B

Explanation

A. A low-sodium diet is not appropriate for a child with Addison's disease. In fact, children with Addison's disease often require higher sodium intake due to the adrenal glands' inability to produce aldosterone, which regulates sodium balance.
B. Cortisol replacement therapy is essential for children with Addison's disease because the condition involves insufficient production of cortisol, a hormone vital for stress response and metabolism. Teaching parents about this therapy is a key nursing intervention to ensure proper management of the disease.
C. Hyperglycemia is not a primary concern in Addison's disease. In fact, the disease is more often associated with hypoglycemia due to low cortisol levels. Therefore, discussing hyperglycemia is not a priority in this case.
D. Fluid volume excess is not typically a concern in Addison's disease. In fact, due to aldosterone deficiency, patients are more prone to dehydration and hypotension, so monitoring for fluid volume deficit is more appropriate.

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Which assessment finding would the nurse expect in a patient diagnosed with acute pericarditis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

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