Cardiac tamponade is suspected in a client 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).

Question

Quizplus · Accepted Answer

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.

Cardiac Tamponade Is Suspected in a Client Who Has Acute