Which assessment finding obtained by the nurse when assessing a ...

[casperchen82]

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

Question 2

Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider?
 
  a. Generalized muscle aching
  b. Sudden onset right flank pain
  c. Janeway's lesions on the palms
  d. Temperature 100.7 F (38.1 C)

[joechoochoy]

Answer to Question 1

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.

Answer to Question 2

ANS: B
Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions.