Nokea
The nurse notes that there is a difference in a patient's blood pressure (BP) and heart rate (HR) when the patient changes position from supine to standing. The differences are a decrease of 20 mm Hg in systolic BP, a decrease of 10 mm Hg in diastolic BP, and an increase in the HR of 20 beats/minute. Which interpretation would the nurse make about the patient's condition?
- A. Hypertensive crisis.
- B. An auscultatory gap.
- C. Resistant hypertension.
- D. Enlarged lymph nodes.
Correct Answer: B
Rationale: The described changes suggest an auscultatory gap, a phenomenon during BP measurement that can lead to inaccurate readings, requiring careful technique.
You may also like to solve these questions
The nurse recognizes that patients with von Willebrand disease are at risk for prolonged bleeding times for which reason?
- A. Adequate platelet production.
- B. Deficiency in intrinsic clotting system factor.
- C. Impairment of the thrombin fibrinogen reaction.
- D. Variable factor VIII deficiencies and platelet dysfunction.
Correct Answer: D
Rationale: Von Willebrand disease involves variable factor VIII deficiencies and platelet dysfunction, leading to prolonged bleeding times due to impaired clot formation.
The arterial blood gas (ABG) results for a patient who overdosed on barbiturates are pH = 7.32, PaCO2 = 52, and HCO3 = 23. Which interpretation would the nurse rely on when planning the patient's care?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: The given ABG results indicate a low pH (acidosis), an elevated PaCO2 (respiratory component), and a normal HCO3 (metabolic component). The low pH and increased PaCO2 suggest respiratory acidosis.
Which information would the nurse include when discussing pain due to chronic stable angina with the patient?
- A. Occurs with both activity and rest.
- B. Generally lasts 10-15 minutes or more.
- C. Does not subside when the precipitating factor is resolved.
- D. Occurs intermittently over a period of time in a similar pattern.
Correct Answer: D
Rationale: Chronic stable angina occurs intermittently in a predictable pattern, triggered by exertion and relieved by rest or nitroglycerin.
Which component forms an adhesive bridge between platelets and vascular subendothelial structures in the clotting process?
- A. Serotonin.
- B. Platelet factor III.
- C. Von Willebrand factor.
- D. Adenosine diphosphate.
Correct Answer: C
Rationale: Von Willebrand factor forms an adhesive bridge between platelets and vascular subendothelial structures, crucial for hemostasis at sites of vascular injury.
Which information would the nurse include when discussing pain due to chronic stable angina with the patient?
- A. Occurs with both activity and rest.
- B. Generally lasts 10-15 minutes or more.
- C. Does not subside when the precipitating factor is resolved.
- D. Occurs intermittently over a period of time in a similar pattern.
Correct Answer: D
Rationale: Chronic stable angina follows a predictable pattern, occurring intermittently with exertion and subsiding with rest, not typically at rest.