Week 2 Flashcards
A 70 year old patient is to have her blood pressure checked each shift. She asks the nurse to explain her hypertension. An appropriate response from the nurse is that older people often experience hypertension because of:-
A) myocardial damage
B) ingestion of high processed foods high in sodium
C) reduction in physical activity
D) physical inactivity and/ or high dietary salt intake
E) sleeping less
A) myocardial damage
B) ingestion of high processed foods high in sodium
C) reduction in physical activity
D) physical inactivity and/ or high dietary salt intake*
E) sleeping less
A nurse has just taken the vital signs of a 30 year old patient. Based on the results, which of the following findings will the nurse report to be out of the expected range for a patient this age? A) resps 20 breathes per min B) pulse 105 bpm C) pulse 64 bpm D) temperature 37.0 C E) BP 120/76 mmHg
A) resps 20 breathes per min B) pulse 105 bpm* C) pulse 64 bpm D) temperature 37.0 C E) BP 120/76 mmHg
The nurse explains to the nursing assistant that a false reading of high blood pressure may result if the assistant:
A) wraps the cuff too loosely around the arm
B) deflates the cuff too quickly
C) presses the stethoscope too firmly in the antecubital fossa
D) repeats the blood pressure assessment too soon
E) pumps up the cuff too quickly
A) wraps the cuff too loosely around the arm*
B) deflates the cuff too quickly
C) presses the stethoscope too firmly in the antecubital fossa
D) repeats the blood pressure assessment too soon
E) pumps up the cuff too quickly
The patient recently became febrile and stated he “felt hot”. You take the patients temperature and find it to be 38.2* C. In addition, the pulse is 88 beats per minute, and his blood pressure is 160/80 mmHg. Which of the following is an example of subjective data?
A) the blood pressure of 168/80 mmHg
B) the clients statement about feeling hot
C) the fact that he became febrile
D) there is no subjective evidence given here
E) the pulse is 88 bpm
A) the blood pressure of 168/80 mmHg
B) the clients statement about feeling hot*
C) the fact that he became febrile
D) there is no subjective evidence given here
E) the pulse is 88 bpm
As the patient’s nurse you are ready to take vital signs. The patient has just enjoyed an ice-cream. An appropriate action would be to:
A) get the patient to rinse their mouth out with warm water
B) take the temperature rectally
C) wait 20-30 mins and take the oral temperature
D) come back in 10 mins and take the oral temperature
E) take it orally as planned
A) get the patient to rinse their mouth out with warm water
B) take the temperature rectally
C) wait 20-30 mins and take the oral temperature *
D) come back in 10 mins and take the oral temperature
E) take it orally as planned
A patient appears to be breathing faster than before. The nurse should:
A) immediately inform the doctor
B) take the radial pulse
C) ask the patient if there have been any stressful visitors
D) get the patient to lie down
E) count the respirations
A) immediately inform the doctor B) take the radial pulse C) ask the patient if there have been any stressful visitors D) get the patient to lie down E) count the respirations*
The nurse writes the following goal for a patient who is hypertensive: “patient will maintain a blood pressure within acceptable limits.” . Which one of the following would be the most appropriate outcome criterion?
A) patient will request pain medication as needed
B) patient will have a 7a.m blood pressure reading less than 140/90mmHg
C) patient will identify at least two things that cause stress
D) patient will experience no headache or dizziness
E) patient will have a normal blood pressure at all times
A) patient will request pain medication as needed
B) patient will have a 7a.m blood pressure reading less than 140/90mmHg*
C) patient will identify at least two things that cause stress
D) patient will experience no headache or dizziness
E) patient will have a normal blood pressure at all times
A patient has bilateral casts on the upper extremities, so the nurse will be measuring blood pressure in the leg. The nurse expects diastolic pressure to be:
A) essentially the same as that in the brachial artery
B) 50mmHg higher than in the brachial artery
C) 20-30mmHg lower than in the brachial artery
D) 10-40mmHg higher than in the brachial artery
E) you should not conduct a BP in the leg
A) essentially the same as that in the brachial artery*
B) 50mmHg higher than in the brachial artery
C) 20-30mmHg lower than in the brachial artery
D) 10-40mmHg higher than in the brachial artery
E) you should not conduct a BP in the leg
