Question

A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

Incompetent mitral valve Inability of the atria to contract Inflammation of the pericardial sac Increased pressure within the ventricle

Answer 1

Inflammation of the pericardial sac is the process that would have occurred within the pericardium.

Step-by-step explanation:

• Post myocardial infarction (MI), pericardial inflammation or early pericarditis is a complication that usually occurs within the first 24-96 hour time period.
• The high-pitched, scratchy, scraping sound heard with an increase in exhalation when the client leans forward is due to the increased pericardial frictional rub of the inflamed pericardial layers in the pericardial sac.
• These heart sounds are typical of pericarditis and can be best heard during inspiration as well as forced expiration with the patient in the forward-leaning position.