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Which of the following assessment data 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 166/90
- C. Jugular vein distension (JVD) to the level of the jaw
- D. Level 6 (0-10 scale) chest pain with deep inspiration
Correct Answer: C
Rationale: 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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The nurse is conducting discharge teaching about the need for prophylactic antibiotics when having dental procedures. This teaching would be provided to a patient with which of the following diagnoses?
- A. Acute myocardial infarction
- B. Exacerbation of heart failure
- C. Mechanical mitral valve replacement
- D. Rheumatic fever after a streptococcal infection
Correct Answer: C
Rationale: Current guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.
The nurse is assessing a patient who has mitral valve regurgitation. Which of the following findings should be communicated to the health care provider immediately?
- A. 4+ peripheral edema in both legs
- B. Crackles audible to the lung apices
- C. A palpable thrill felt over the left anterior chest
- D. A loud systolic murmur all across the precordium
Correct Answer: B
Rationale: Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.
The nurse is assessing a patient with infective endocarditis (IE). Which of the following findings should the nurse expect to assess?
- A. A new regurgitant murmur
- B. A pruritic rash on the trunk
- C. Involuntary muscle movement
- D. Substernal chest pain and pressure
Correct Answer: A
Rationale: New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.
The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which of the following information obtained by the nurse is most relevant?
- A. The patient reports using cocaine once at age 16.
- B. The patient has a history of a recent upper respiratory infection.
- C. The patient's 29-year-old brother had a sudden cardiac arrest.
- D. The patient has a family history of coronary artery disease.
Correct Answer: C
Rationale: About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people, the information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against use of stimulant drugs, but the one-time use indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC.
Cardiac tamponade is suspected in a patient who has acute pericarditis. Which of the following actions should the nurse implement to assess for the presence of pulsus paradoxus?
- A. Check the electrocardiogram (ECG) for variations in rate in relation to inspiration and expiration
- B. Note when Korotkoff sounds are audible during both inspiration and expiration.
- C. Auscultate for a pericardial friction rub that increases in volume during inspiration.
- D. Subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
Correct Answer: B
Rationale: 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.