The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should
a. note when Korotkoff sounds are auscultated during both inspiration and expiration.
b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
c. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle.
d. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.
ANS: A
Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.
You might also like to view...
What should the nurse stress to a post-hip replacement patient in quadriceps setting exercises?
a. Push knee down to mattress and raise heel off the bed b. Flex knee and extend foot c. Adduct leg and flex foot d. Lift leg and heel off the bed
When working with a victim of family interpersonal violence, the most therapeutic intervention is to:
A) Point out the client's inability to change the situation. B) Allow the client to decide when it is safe to leave the abuser. C) Refrain from direct questions about family violence, as this will intimidate the victim. D) Invite the abuser to the assessment session.
Which of the following statements by a parent indicates a need for increased learning regarding appropriate (nonabusive) discipline of a child?
a. "I have stopped using a switch on my child, and I am learning to count to 10 before reacting." b. "I never spank or hit; I yell at them to stop being stupid, and if they don't, I tell them no one is ever going to love them if they act like that." c. "I use time-outs when my child acts out or is naughty. Sometimes my child doesn't cope well with this, but I am persistent." d. "When my child misbehaves, I distract him and focus his attention on other things. If he throws a tantrum, I have been known to just pick him up and leave from wherever we are."
Develop a teaching plan for R.T. focusing on the common effects of diarrhea, alopecia, and
nausea and vomiting. Diarrhea: What will be an ideal response?