# A nurse is caring for a patient with acute pericarditis. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540283 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient with acute pericarditis. Which nursing intervention should be the priority? ## 보기 1. Administer prescribed anti-inflammatory medication immediately 2. Encourage frequent ambulation and deep breathing exercises 3. Position the patient in high Fowler's position or leaning forward **✔ 정답** 4. Apply cold compresses to the chest area for pain relief **정답: 3** ## 해설 Positioning in high Fowler's or leaning forward is the priority to relieve pericarditis pain by reducing pericardial pressure. Other options are less effective: antibiotics treat infection (not always present), deep breathing may worsen pain, and heat packs are not standard. ## 심화 해설 Understanding Acute Pericarditis Pathophysiology Acute pericarditis is an inflammatory condition of the pericardium, the fibroelastic sac surrounding the heart. The core issue is inflammation, which can lead to the accumulation of fluid (pericardial effusion) in the pericardial space. As demonstrated in the case of MRSA pericarditis [1], this inflammation and fluid buildup can progress to a life-threatening complication called cardiac tamponade, where the fluid pressure compresses the heart, preventing it from filling properly and drastically reducing cardiac output. The primary symptom is sharp, pleuritic chest pain that is characteristically positional. Priority Nursing Intervention and Rationale The correct answer is to position the patient in high Fowler's position or leaning forward. This is the priority nursing intervention because it directly addresses the hallmark symptom of acute pericarditis and provides immediate, non-pharmacological pain relief. The pain of pericarditis is caused by the inflamed layers of the pericardium rubbing against each other. When the patient sits up and leans forward, the heart falls away from the chest wall, reducing this friction and significantly alleviating pain. This intervention is a rapid, independent nursing action that can be implemented immediately upon assessment. Analysis of Incorrect Options - **Option 1: Administer prescribed anti-inflammatory medication immediately.** While pharmacotherapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine is the cornerstone of medical management for acute pericarditis, this is not the nurse's first priority. The case of recurrent pericarditis [2] highlights that initial treatment with steroids, rather than colchicine, is a risk factor for recurrence, underscoring the importance of the correct medication regimen. However, administering medication requires a prescription and verification process, whereas positioning the patient for comfort is an immediate, independent nursing action that can be performed without delay. - **Option 2: Encourage frequent ambulation and deep breathing exercises.** This intervention is contraindicated in the acute phase of pericarditis. Ambulation and deep breathing increase intrathoracic pressure and exacerbate the friction between the inflamed pericardial layers, intensifying pain. Rest is recommended until pain and fever subside. - **Option 4: Apply cold compresses to the chest area for pain relief.** This is not a standard or effective intervention for pericarditis pain. The pain originates from deep inflammation, not a superficial musculoskeletal issue, and cold application would not address the underlying pathophysiology of pericardial friction. Clinical Application and NCLEX-RN Focus For the NCLEX-RN, understanding the prioritization of nursing actions is critical. In a patient with acute pericarditis presenting with chest pain, the nurse's first action is always to position the patient to relieve pain. This follows the ABC (Airway, Breathing, Circulation) and comfort-pain framework. By easing the pain, the nurse can also improve breathing, as deep inspiration is typically painful. The case of post-cardiac injury syndrome explains that the condition is an immune-mediated inflammatory response, which reinforces why anti-inflammatory drugs are the definitive treatment, but positioning is the immediate nursing priority. Furthermore, a vigilant nurse must monitor for signs of cardiac tamponade—such as muffled heart sounds, hypotension, and jugular venous distension (Beck's triad)—especially in cases with a large effusion, as described in the MRSA pericarditis case [1]. A case of radiation-induced pericarditis also emphasizes that prompt recognition of the characteristic positional chest pain is key to early diagnosis and management. References (research sources) - [1]Parasternal Pericardiocentesis for Methicillin-Resistant Staphylococcus aureus Pericarditis Complicated by Abscess and Tamponade.Research articlePrabhu SS, Malhotra S, Hajjar R, Mazzaferri EL, Boudoulas KD, Gil K, Liu E. (2025) · DOI: 10.1016/j.jaccas.2025.105922 - [2]Recurrent Acute Pericarditis Complicated by Constriction in T-Cell Acute Lymphoblastic Leukemia: Role of Multimodality Imaging.Research articleOjo NJ, Loccoh EC, Pabon MA, Cuddy S, Weber BN. (2025) · DOI: 10.1016/j.jaccas.2025.104160 ## 임상 시나리오 Pericarditis Pain: Positioning FirstImmediate non-pharmacological comfort measure The hallmark of acute pericarditis is sharp, pleuritic chest pain that is aggravated by lying supine and relieved by sitting upright and leaning forward. This positional change reduces friction between the inflamed pericardial layers. As a priority nursing action, position the patient in High Fowler's position or have them lean forward over a bedside table. This is an independent intervention that provides rapid pain relief by allowing the heart to fall away from the chest wall. CautionAvoid interventions that exacerbate pain, such as encouraging deep breathing or ambulation. Monitor for signs of cardiac tamponade (muffled heart sounds, hypotension, distended neck veins), a life-threatening complication of pericardial effusion. ## 핵심 개념 - **Pericarditis** — Inflammation of the pericardial sac, often causing sharp, pleuritic chest pain that improves when leaning forward. - **Pleuritic Pain** — Chest pain that worsens with inspiration or coughing, characteristic of pericardial or pleural inflammation. - **High Fowler's Position** — A sitting position with the head of the bed elevated 60 to 90 degrees, used to maximize chest expansion and comfort. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old patient with systemic lupus erythematosus who presents …](https://mymerci.kr/pages/nclex_q.php?qn_id=540281) - [A nurse is assessing a 38-year-old patient admitted with suspected pericarditis. Which ass…](https://mymerci.kr/pages/nclex_q.php?qn_id=540282) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._