Which of the following assessment data obtained by the nurse when assessing a client with acute pericarditis should be reported immediately to the health care provider?
A)Pulsus paradoxus 8 mm Hg
B)Blood pressure (BP) of 166/96
C)Jugular vein distension (JVD) to the level of the jaw
D)Level 6 (0-10 scale) chest pain with deep inspiration

Question

Quizplus · Accepted Answer

The JVD indicates that the client 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.

Which of the Following Assessment Data Obtained by the Nurse