Chapter 25 Prep U, Test Questions and answers. 100% proven pass rate.

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Chapter 25 Prep U, Test Questions and answers. 100% proven pass rate. A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commo... de. Which health problem should the nurse consider when client falls occur? - ✔✔orthostatic hypotension Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness. Dyspnea is difficult or labored breathing. Essential or primary hypertension is high blood pressure. Secondary hypertension (secondary high blood pressure) is high blood pressure that's caused by another medical condition. When assessing an infant's axillary temperature, it will be: - ✔✔1°F (0.5°C) lower than an oral temperature. Rectal temperatures may be 1°F (0.5°C) higher than oral temperatures and axillary temperatures are 1°F (0.5°C) lower than oral temperatures. A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will: - ✔✔decrease the apical pulse. Certain cardiac medications, such as digoxin, decrease the heart rate. Which pulse site is generally used in emergency situations? - ✔✔carotid The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds.Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess. A pulse deficit is the difference between: - ✔✔the apical and the radial pulse rates. When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate. The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? - ✔✔deep in the posterior sublingual pocket When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe. An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began measuring the BP after she arose from her nap and found that her BP would drop from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client? - ✔✔You may have orthostatic hypotension and should be seen by your health care provider as soon as you can. Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls. A client with newly diagnosed hypertension on BP medication has been taking her own BP at home for 2 weeks. When she calls and reports her BP readings to the nurse, the nurse notes an elevated BP in the morning. The client states that she wakes up, has her daily cup of coffee, and takes her BP before eating as she was instructed. What should the nurse recommend to this client? - ✔✔Take her BP before drinking her morning cup of coffee.A client should be taught to avoid food, coffee, and alcohol 30 minutes before taking a measurement. There is no need for this client to come immediately to the office; it is usually recommended that clients take their BP in the morning and the evening to get a record of BP readings over time. The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? - ✔✔Remove the thermometer and assess the blood pressure and heart rate. Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens. The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart? - ✔✔Listen for heart sounds. The apex of the heart is found by palpating between the fifth and sixth ribs, then moving the stethoscope to the left midclavicular line. The apical rate is typically assessed for 1 minute. Each "lubdub" sound counts as one beat. A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client? - ✔✔rectum The rectal temperature, a core temperature, is considered to be one of the most accurate routes. The most practical and convenient sites for temperature measurement are the ear, mouth, and axilla. These areas are anatomically close to superficial arteries containing warm blood, enclosed areas where heat loss is minimal, or both. Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? - ✔✔palpation of the radial pulse on the thumb side of the inner aspect of the wrist.The radial artery is the site most commonly assessed in the clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. When taking the client's temperature, the student nurse will require further education when they state: - ✔✔"The axillary route is the most accurate of all routes." Use judgment when selecting the route to measure temperature. The most commonly used sites are the mouth, rectum, ear (tympanic), forehead (temporal artery), and axilla. The least accurate temperature measurement is the axilla because it can register up to a degree lower than rectal or other methods of taking the internal temperature. Rectal temperature is contraindicated for cardiac clients as it can cause the client to vasovagal and cause a lethal arrhythmia. The use of disposable probes is important when taking temperature as it reduces transmission of pathogens between clients. The oral temperature should be avoided in children as they are mouth breathers and this would affect the temperature. A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? - ✔✔"Dizziness when you change position can occur when fluid volume in the body is decreased." Dehydration is a cause for orthostatic hypotension, which causes a temporary drop in BP when the client rises from a reclining position. Dizziness is not associated with environmental changes. Dizziness or changes in orthostatic BP occurs when baroreceptors do not respond quickly enough to restore adequate circulation to the brain. Dizziness may be caused by low blood pressure. However, the client is dizzy with ambulation not when lying down. When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next? - ✔✔Auscultate the apical pulse for 60 seconds Palpating the radial pulse is the most convenient method for assessing the pulse but not always the most accurate. Because the rhythm is irregular, a more accurate assessment method is required for a full minute. Auscultating the apical pulse for a full minute provides more accuracy. The other interventions would be implemented after a more accurate assessment is obtained. [Show More]

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