The nurse suspects cardiac tamponade in a patient who has acute ...

[soccerdreamer_17]

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.

Question 2

To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should
 
  a. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.
  b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.
  c. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub.
  d. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.

[carlsona147]

Answer to Question 1

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.

Answer to Question 2

ANS: B
Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.