The patient presents to the emergency room (ER) after having a fever for three days and new onset severe chest pain behind the sternum. The patient asks, “What is wrong with me? Do I have pneumonia? It hurts when I breathe.” Upon assessment, the nurse notes a heart rate of 124 bpm, temperature of 37.9°C, and an intermittent friction rub upon auscultation. The lungs are clear. The nurse suspects further testing will lead to a diagnosis of which condition?

Which interventions increase the risk for impaired skin integrity in the patient with congestive heart failure who requires total care? Select all that apply.

The nurse is assigned to a patient with malignant hypertension. The patient acutely develops mid-sternal “tearing” chest pain that radiates to the back. Which of the following additional clinical signs is most likely to be present in this patient?