Question

A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus?

1. Measure blood pressure in the right arm, then in the left arm as the client slows the pace of their inhalations and exhalations.
2. Measure blood pressure in either arm with the client holding their breath, then with the client breathing normally.
3. Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally.
4. Measure the blood pressure in the right arm as the client inhales slowly, then measure the blood pressure in the left arm as the client exhales slowly.

Answer 1

To assess pulsus paradoxus, the nurse should measure blood pressure in either arm with the client holding their breath and then with the client breathing normally.

Step-by-step explanation:

To assess a client for pulsus paradoxus, the nurse should measure blood pressure in either arm with the client holding their breath, and then again with the client breathing normally.

Pulsus paradoxus is a clinical finding where the systolic blood pressure decreases by more than 10 mmHg during inspiration. It is commonly seen in cardiac tamponade, which is the excessive accumulation of fluid in the pericardial sac surrounding the heart.