Nokea
Postural Hypotension is A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
- A. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
- B. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
- C. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
Correct Answer: A
Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension.
Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.
You may also like to solve these questions
A client with neuromuscular disorder is receiving intensive nursing care. The client is likely to face the risk for impaired skin integrity. Which of the ff must the nurse ensure to prevent skin breakdown in the client?
- A. Prevent strenuous exercises by the client
- B. Use pressure relieving devices when the client is in bed
- C. Place the client in Fowler’s position
- D. Avoid giving daily baths with soaps to the client
Correct Answer: B
Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown.
Incorrect choices:
A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case.
C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity.
D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.
The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
- A. Gordon’s Functional Health Patterns
- B. Activity-exercise pattern assessment
- C. General to specific assessment
- D. Problem-oriented assessment
Correct Answer: C
Rationale: The correct answer is C: General to specific assessment. This type of assessment approach involves starting with a broad overview of the patient's condition and then narrowing down to specific details. In this scenario, the nurse begins by examining the surgical dressing, which is a specific aspect of the patient's condition, after which they can proceed to gather more detailed information about the drainage, wound healing, and any associated symptoms. This approach allows the nurse to systematically assess the patient's postoperative status and identify any potential issues.
A: Gordon’s Functional Health Patterns is a comprehensive framework for organizing patient data, but it does not specifically address the sequence of assessment in this scenario.
B: Activity-exercise pattern assessment focuses on the patient's activity level and exercise habits, which is not the primary concern in this situation.
D: Problem-oriented assessment involves identifying and addressing specific health problems, but it does not capture the systematic progression from general to specific assessment as seen in this scenario.
A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? “Evaluative measures are multiple-page documents used to evaluate nurse
- A. performance.” NursingStoreRN “Evaluative measures include assessment data used to determine whether patients
- B. have met their expected outcomes and goals.” “Evaluative measures are used by quality assurance nurses to determine the progress
- C. a nurse is making from novice to expert nurse.”
- D. “Evaluative measures are objective views for completion of nursing interventions.”
Correct Answer: B
Rationale: The correct answer is B because evaluative measures in nursing refer to the assessment data used to determine if patients have achieved their expected outcomes and goals. This is crucial in evaluating the effectiveness of the care provided.
Choice A is incorrect because it defines evaluative measures as multiple-page documents, which is not accurate. Choice C is incorrect as it focuses on the progression of a nurse's skill level rather than patient outcomes. Choice D is incorrect as it defines evaluative measures as objective views of completing nursing interventions, which is too narrow of a definition.
Aling Loida, who was admitted for acute pancreatitis, starts complaining of acute abdominal pain, which of the following would be an appropriate nursing interventions by Nurse Norma?
- A. administer morphine sulfate as ordered
- B. obtain daily weights
- C. maintain Aling Loida on high calorie, high protein diet
- D. place her on supine position
Correct Answer: A
Rationale: The correct answer is A: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being.
Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.
The nurse knows that Parkinson’s disease a progressive neurologic disorder is characterized by:
- A. Bradykinesia
- B. Tremor
- C. Muscle rigidity
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.