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What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?
- A. The popliteal artery should be auscultated to obtain thigh pressure.
- B. The best position to measure thigh pressure is the prone position.
- C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
- D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.
Correct Answer: C
Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.
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A patient is seen in the clinic for reports of "fainting episodes that started last week."? How would the nurse proceed with the examination?
- A. Blood pressure readings are taken in both arms and thighs.
- B. The patient is assisted to a lying position, and their blood pressure is taken.
- C. The patient's blood pressure is recorded in lying, sitting, and standing positions.
- D. The patient's blood pressure is recorded in lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.
Correct Answer: C
Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure. Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.
A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these
actions is most appropriate when the nurse is assessing an infant's vital signs?
- A. The infant's radial pulse should be palpated, and the nurse should notice any
fluctuations resulting from activity or exercise. - B. The nurse should auscultate an apical rate for 1 minute and then assess for any
normal irregularities, such as sinus dysrhythmia.
- C. The infant's blood pressure should be assessed by using a stethoscope with a large
diaphragm piece to hear the soft muffled Korotkoff sounds. - D. The infant's chest should be observed and the respiratory rate counted for 1
minute; the respiratory pattern may vary significantly.
Correct Answer: B
Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be
counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus
dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently,
hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic
blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.
An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because
an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate
an apical heart rate, not palpate a radial pulse, with infants and toddlers.
The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature"?36°C; pulse"?48 beats per minute; respirations"?14 breaths per minute; blood pressure"?104/68 mm Hg. Which statement is true concerning these results?
- A. The patient is experiencing bradycardia.
- B. These are normal vital signs for a healthy, athletic adult.
- C. The patient's pulse rate is not normal"?no action is required.
- D. The patient's next clinic visit should occur as scheduled.
Correct Answer: B
Rationale: The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness. Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive
drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?
- A. Blood pressure and pulse should be recorded in the supine, sitting, and standing
positions. - B. The patient should be directed to walk around the room and his blood pressure
assessed after this activity. - C. Blood pressure and pulse are assessed at the beginning and at the end of the
examination. - D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
Correct Answer: A
Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive
medications, when the person reports fainting or syncope, or when volume depletion is suspected.
The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.
A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?
- A. A history of hepatitis C five years previously
- B. Cholecystitis requiring cholecystectomy one year previously
- C. Asymptomatic diverticulosis
- D. Crohn's disease in remission
Correct Answer: A
Rationale: A history of hepatitis C five years previously would prevent a donor from donating blood for transfusion. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis requiring cholecystectomy one year previously, asymptomatic diverticulosis, and Crohn's disease in remission are not contraindications for blood donation as they do not pose a risk of transmitting infections to the recipient.