Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?
a. Pulsus paradoxus 8 mm Hg
b. Blood pressure (BP) of 168/94
c. Jugular venous distention (JVD) to jaw level
d. Level 6 (0 to 10 scale) chest pain with a deep breath
ANS: C
The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis.
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