Vital Signs Assessment

Vital Signs Assessment Related

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A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:

  • A. Collect a follow-up data base and then check her blood pressure.
  • B. Ask her to read her health record and indicate any changes since her last visit.
  • C. Check only her blood pressure because her complete health history was documented 2 months ago.
  • D. Obtain a complete health history before checking her blood pressure because much of her history information may have changed.
Correct Answer: A

Rationale: The correct answer is A because collecting a follow-up data base allows the nurse to assess any changes in the patient's health status since her last visit, including evaluating the effectiveness of the new medication on her blood pressure. This step is essential to ensure the patient's ongoing care is appropriate and effective.

Option B is incorrect because asking the patient to read her health record may not provide a comprehensive update on her current health status. Option C is incorrect as the patient's health history may have changed within the 2-month period, necessitating a reassessment. Option D is incorrect as obtaining a complete health history before checking her blood pressure may delay the assessment and may not be necessary for a routine follow-up visit.

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A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?

  • A. stroke
  • B. anemia
  • C. cancer
  • D. infection
Correct Answer: A

Rationale: Stroke is the greatest risk with long-term hypertension, per the answer key, due to arterial damage. Anemia , cancer , and infection aren't directly linked. Nurses prioritize stroke prevention in hypertensive patients, a key chronic disease outcome.

The nurse is performing a respiratory assessment and notes that the patient has crackles in the lower lung fields. What is the most likely cause of this finding?

  • A. Pleural effusion.
  • B. Pneumonia.
  • C. Pulmonary edema.
  • D. Chronic obstructive pulmonary disease (COPD).
Correct Answer: C

Rationale: The correct answer is C: Pulmonary edema. Crackles in the lower lung fields are indicative of fluid accumulation in the alveoli, which is characteristic of pulmonary edema. This condition is commonly seen in heart failure when the heart is unable to effectively pump blood, leading to fluid backup in the lungs. Pleural effusion (A) is the accumulation of fluid in the pleural space, not in the alveoli. Pneumonia (B) typically presents with other symptoms like fever and productive cough. COPD (D) is characterized by airflow limitation and is not directly associated with crackles due to fluid accumulation.

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview?

  • A. I sleep like a baby
  • B. I have no health problems
  • C. I never did too good in school
  • D. I am not currently taking any medications
Correct Answer: C

Rationale: The correct answer is C: "I never did too good in school." This statement indicates potential underlying issues like learning disabilities or lack of education, affecting the patient's understanding of health information. The nurse should explore this further to assess the patient's health literacy. Choices A, B, and D are less critical as they do not directly impact the patient's health status or the interview process.

What would a nurse ensure before beginning a health assessment?

  • A. that the time needed for the assessment fits into the nurses work schedule
  • B. that the room is private, quiet, warm, and has adequate light
  • C. that family members are present to answer specific questions
  • D. that there is a written physicians order for the assessment
Correct Answer: B

Rationale: A private, quiet, warm, well-lit room , per the answer key, ensures comfort and accuracy. Scheduling , family presence , or physician orders are secondary or unnecessary. Nurses, per Taylor, create optimal environments for effective assessments.

The cruciate ligaments of the knee lie in which of the following locations?

  • A. Inside the joint capsule and synovial cavity
  • B. Outside the synovial cavity but within the fibrous joint capsule
  • C. Outside the fibrous joint capsule
  • D. Outside both the synovial and fibrous joint capsules
Correct Answer: B

Rationale: The correct answer is B: Outside the synovial cavity but within the fibrous joint capsule. The cruciate ligaments of the knee are located within the joint capsule, which is a fibrous structure surrounding the knee joint. They are positioned outside the synovial cavity, which is the space within the joint capsule that contains synovial fluid. This location allows the cruciate ligaments to provide stability to the knee joint without being directly exposed to the synovial fluid. Choices A, C, and D are incorrect because they do not accurately describe the specific location of the cruciate ligaments within the knee joint.