Medical Surgical Pericarditis #2

Question

The emergency department (ED) nurse is assessing a client who arrived with severe retrosternal chest pain described as burning and sharp which worsens on inspiration. The health care provider diagnoses the client with acute pericarditis. Which finding is most consistent with this diagnosis?

Answers

  1. Wheezes
    • Rationale:

      This answer is not correct because wheezes are high pitched and may be during inspiration or expiration and are caused by constriction or swelling of the airway. They are not diagnostic for acute pericarditis. The finding most consistent with pericarditis is friction rub, a scratching, grating sound similar to leather rubbing against leather.

  2. Friction rub
    • Rationale:

      This answer is correct because pericarditis is the inflammation of the membranous sac that surrounds the heart. The finding most consistent with pericarditis is friction rub, a scratching, grating sound similar to leather rubbing against leather.

  3. Fine crackles
    • Rationale:

      This answer is not correct because fine or coarse crackles are caused by fluid in small airways and are discontinuous sounds created by air forced through narrowed respiratory passages caused by fluid or mucus and are associated with infection or inflammation. Fine crackles are soft, high-pitched while coarse crackles are louder and lower in pitch. The finding most consistent with pericarditis is friction rub, a scratching, grating sound similar to leather rubbing against leather.

  4. Coarse crackles
    • Rationale:

      This answer is not correct because fine or coarse crackles are caused by fluid in small airways and are discontinuous sounds created by air forced through narrowed respiratory passages caused by fluid or mucus and are associated with infection or inflammation. Fine crackles are soft, high-pitched while coarse crackles are louder and lower in pitch. The finding most consistent with pericarditis is friction rub, a scratching, grating sound similar to leather rubbing against leather.

Overview

Pericarditis is the inflammation of the membranous sac that surrounds the heart. The finding most consistent with pericarditis is friction rub.

Explanation

Learning Outcomes

Pericarditis is the inflammation of the membranous sac that surrounds the heart. The finding most consistent with pericarditis is a pleural friction rub. A pleural friction rub has a scratching, grating sound similar to leather rubbing against leather. Auscultation is best heard with the diaphragm of the stethoscope over the left lower sternal edge or apex during end expiration while the client is sitting up and leaning forward.

Test Taking Tip

Being able to eliminate choices is just as important as selecting choices correctly. Knowing what is not the correct answer may be what NCLEX questions are wanting you to demonstrate.

Video Rationale