Nokea
When considering the concepts related to blood pressure, which statement best describes the concept of mean arterial pressure (MAP)?
- A. MAP is the pressure of the arterial pulse.
- B. MAP reflects the stroke volume of the heart.
- C. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
- D. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.
Correct Answer: C
Rationale: Mean Arterial Pressure (MAP) is the pressure that forces blood into the tissues, averaged over the cardiac cycle. It is not the pressure of the arterial pulse (Choice A), nor does it directly reflect the stroke volume of the heart (Choice B). While MAP involves systolic and diastolic pressures, it is not simply an average of these two values as diastole lasts longer. Instead, MAP is closer to diastolic pressure plus one third of the pulse pressure. The best description of MAP is that it represents the pressure forcing blood into the tissues, averaged over the cardiac cycle.
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When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?
- A. The body temperature of the older adult is lower than that of a younger adult.
- B. An older adult's body temperature is approximately the same as that of a young child.
- C. Body temperature varies based on the type of thermometer used.
- D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.
Correct Answer: A
Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2°C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to an LPN/LVN?
- A. Complete admission assessment.
- B. Set up oxygen and suction equipment.
- C. Place a padded tongue blade at the bedside.
- D. Pad the side rails before the patient arrives.
Correct Answer: B
Rationale: The correct answer is to delegate the task of setting up oxygen and suction equipment to the LPN/LVN. This task falls within their scope of practice and can be safely performed by them. Completing the admission assessment (Choice A) typically requires a higher level of assessment and critical thinking, making it more appropriate for a registered nurse. Placing a padded tongue blade at the bedside (Choice C) involves potential airway management, which is a more complex task and should be done by a higher-level provider. Padding the side rails before the patient arrives (Choice D) is a task related to patient safety and should be done by the healthcare team as a whole, not solely delegated to an LPN/LVN.
Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?
- A. Sports and games with rules.
- B. Finger paints and water play.
- C. "Dress-up"? clothes and props.
- D. Chess and television programs
Correct Answer: A
Rationale: For 7-year-old children, play serves an important role in developing cooperation, logical reasoning, and social skills. Organizing sports and games with rules is beneficial as it helps children understand the importance of rules, promotes teamwork, and fosters social interactions. Finger paints and water play, while fun, may not target the specific developmental needs of this age group. Similarly, 'Dress-up' clothes and props can encourage imaginative play but may not necessarily promote cooperation and logical reasoning. Chess and television programs are more suited for older children and may not engage 7-year-olds as effectively in developing the desired skills.
The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?
- A. "Measuring temperature using the TMT is cost-effective."?
- B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
- C. "TMT is not recommended for measuring core body temperature in newborn infants."?
- D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?
Correct Answer: B
Rationale: The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.
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.