Showing posts with label Health Promotion and Maintenance. Show all posts

To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap.. inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable

To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, nurse Jackie should:

A- have the client lie down while taking his blood pressure.
B- inflate the cuff to at least 200 mm Hg.
C- take blood pressure readings in both arms.
D- inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.

The most appropriate option to avoid recording an erroneously low systolic blood pressure due to a missed auscultatory gap is:

D. Inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.

Here's why:

A. Have the client lie down while taking his blood pressure:

While lying down can sometimes help hear Korotkoff sounds better, it's not specifically related to recognizing an auscultatory gap.

B. Inflate the cuff to at least 200 mm Hg:

This is unnecessarily high and could cause discomfort for the client. Additionally, it wouldn't guarantee encountering the auscultatory gap in all cases.

C. Take blood pressure readings in both arms:

While this is a good practice for general blood pressure monitoring, it wouldn't directly address the issue of missing the auscultatory gap.

D. Inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable:

This is the recommended technique for detecting the auscultatory gap. The radial pulse disappears when the pressure in the cuff is above the systolic pressure. Inflating an additional 30 mm Hg ensures you're beyond the systolic pressure and into the range where the auscultatory gap might occur. This way, you're more likely to hear the first Korotkoff sounds when they appear, preventing an erroneously low systolic reading.

Therefore, D is the most effective choice for nurse Jackie to avoid missing the auscultatory gap and recording an inaccurate blood pressure.

Remember, it's always important to follow proper blood pressure measurement techniques and adapt them based on the client's individual needs and potential risk factors for auscultatory gaps.

When palpating the bladder of an adult client, nurse Sunshine should identify which finding as normal?

a- A soft, smooth bladder.
b- A hard, rough bladder.
c- A nonpalpable bladder.
d- A palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis.

Answer B.

Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64).

More frequent aches and pains begin in the early late years (ages 65 to 79).

Increase in loss of muscle tone occurs in later years (ages 80 and older).

Accepting limitations while developing assets is socialization development that occurs in adulthood (ages 31 to 45).

Gynocytosis:

Gynocytosis is the condition that affects the eye when the near vision of objects is reduced as age increases.

The mechanisms of this condition are not well known, but research strongly supports the loss of crystalline lens flexibility, despite changes in the lens's curvature due to continuous growth and loss of ciliary muscle strength (as determined by the lens).

myopia:

Like gray hair and wrinkles, myopia is one of the symptoms of the normal course of aging.

The first signs of senile vision - eye strain, difficulty in vision in dim light and problems focusing on small objects or small text - are usually first observed in people between the ages of 40 and 50.

ability to focus:

The ability to focus on close objects decreases in all stages of life, from adjusting (the eye) to about 20 dB (concentration capacity at 50 mm away) in children, 10 dB at 25 (100 mm) and other levels 0.5 to 1 Diopter at age 60 (concentration less than 1-2 meters only).

The maximum expected and minimum length of stay for a corrected patient of a certain age can be determined using the HOFSTER formula: Expected range D == 18.5-0.3 × (age in years), maximum capacity (d) = 25-44 x (age in years) , Minimum (d) = 15 - 0.25 x (age in years).

The term "old man" or "old" and "opia" means "short sightedness", as is commonly known in the medical lexicons "pyramidal eyes".

When auscultating a client’s abdomen, nurse Kelly detects high-pitched gurgles over the lower right quadrant.

Based on this finding, the nurse suspects:

a- decreased bowel motility.

b- increased bowel motility.

c- nothing abnormal.

d- abdominal cramping.

Answer C.

High-pitched gurgles are a normal finding.
Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds.

Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

Symptoms of abdominal pain:

These symptoms are associated with abdominal sounds in some cases, so be aware of them:

Nausea.
Abdominal pain with feeling fullness.
Constipation.
Diarrhea.
Bloody stool.
acidity of the stomach.
Thinness.
Sudden weight loss.

When examining a patient who has abdominal pain a nurse should assess which quadrant?

Place the diaphragm of your stethoscope lightly over the right lower quadrant and listen for bowel sounds. If you don't hear any, continue listening for 5 minutes within that quadrant. Then, listen to the right upper quadrant, the left upper quadrant, and the left lower quadrant.

What does the right lower quadrant do?

The lower left quadrant is where the small intestine, colon, ureter, and major veins or arteries to the veins are located. Lastly, the lower right abdominal area is the site of the appendix, ascending colon, and part of the female reproductive organs.

What is in the lower right quadrant of the abdomen?

Organs found in the right lower quadrant include the appendix, the upper portion of the colon, and the right ovary and the Fallopian tube in women. The right lower quadrant may be assessed when diagnosing appendicitis, in which case, this quadrant would be tender and painful.

When assessing the four quadrants of the abdomen the nurse knows that which of the following are located in the left upper quadrant?

Major Organs in the Four Quadrants

Left Upper Quadrant: Liver, stomach, pancreas, left kidney, spleen, and the left adrenal gland. Right Lower Quadrant: appendix, reproductive organs, right ureter. NOTE: All four quadrants contain portions of the small and large intestines.

What quadrant is the lower right of the patient?

The right lower quadrant (RLQ) is a section of your tummy (abdomen). Look down at your tummy, and mentally divide the area from the bottom of your ribs down to your pubic hair into four quarters. The quarter on your right side below your belly button is your RLQ.

Why does the nurse begin auscultating the abdomen in the right lower quadrant quizlet?

The nurse should begin auscultation in the right lower quadrant (RLQ) and not the left upper quadrant (LUQ). This is because bowel sounds are normally present at the ileocecal valve area in the RLQ.)

What are abnormal bowel sounds?

Decreased or absent bowel sounds often indicate constipation. Increased (hyperactive) bowel sounds can sometimes be heard even without a stethoscope. Hyperactive bowel sounds mean there is an increase in intestinal activity. This may happen with diarrhea or after eating.

What is the abnormal sound of abdomen?

Abdominal sounds may either be classified as normal, hypoactive, or hyperactive. Hypoactive, or reduced, bowel sounds often indicate that intestinal activity has slowed down. On the other hand, hyperactive bowel sounds are louder sounds related to increased intestinal activity.

What do you hear when you Auscultate the abdomen?

Auscultation of the abdomen is performed for detection of altered bowel sounds, rubs, or vascular bruits. Normal peristalsis creates bowel sounds that may be altered or absent by disease. Irritation of serosal surfaces may produce a sound (rub) as an organ moves against the serosal surface.

When the nurse Auscultates the abdomen the assessment should begin in which quadrant?

Begin in the right lower quadrant (RLQ), and move in sequence up to the right upper quadrant (RUQ), left upper quadrant (LUQ), and finally the left lower quadrant (LLQ). Auscultate for bruits over the aorta, renal arteries, iliac arteries, and femoral arteries.

Why does the nurse begin auscultating the abdomen in the right lower quadrant?

Always begin in the right lower quadrant because this is the location of the ileocecal valve, which is a muscular sphincter that allows contents to move from the ileum of the small intestine to the cecum of the large intestine.

When inspecting a client’s skin, nurse Melvin finds a vesicle on the client’s arm.. Circumscribed, elevated, and filled with serous fluid

When inspecting a client’s skin, nurse Melvin finds a vesicle on the client’s arm.
Which description applies to a vesicle?
a- Flat, nonpalpable, and colored.
b- Solid, elevated, and circumscribed.
c- Circumscribed, elevated, and filled with serous fluid.
d- Elevated, pus-filled, and circumscribed.

Answer C.
A vesicle is a circumscribed skin elevation filled with serous fluid.
A flat, nonpalpable, colored spot is a macule.
A solid, elevated, circumscribed lesion is a papule.
An elevated, pus-filled, circumscribed lesion is a pustule.

The vesicle in cellular biology is a cellular cytoplasm that is present inside and outside the cell and consists of a liquid surrounded by a double-layer membrane.
Vesicles are formed naturally during the processes of excretion (cellular output) and absorption (cell entry) and the transfer of substances within the cell, and can be prepared artificial vesicles in this case called lipid particles.
If the membrane is made up of a single lipid layer called vesicles, then monoclonal lipid vesicles, and other so-called platelet vesicles.
The membrane surrounding the cell is also a platelet phase, similar to the plasma membrane and vesicle membrane that can be combined with the plasma membrane to release its extracellular contents.
Giovanni can merge with other organelles in the cell.
The vesicles have different functions, and because they are separated from the cellular cytoskeletal, they may have different properties than the cytoskeletal environment.
For this reason the vesicles are an essential tool used by the cell to regulate the cellular material. Vesicles have a role in metabolism, transport, buoyancy control, temporary storage of food and enzymes, and can act as chambers for chemical reactions.
In 2013 James Rothman, Randy Shekman and Thomas Sodhoff share the Nobel Prize in Medicine or Physiology for their roles in clarifying (based on previous research, some by their teachers) the composition and function of cellular vesicles, particularly in yeast and humans, including information on each part of Vesicle and how to collect them.
Vesicular dysfunction is believed to contribute to Alzheimer's disease, diabetes, some severe epilepsy cases, certain cancers, immune disorders and certain neurological diseases.

Nurse Eve prepares to perform light palpation. How is light palpation performed.. By indenting the skin ½” to ¾” - 1.3 to 1.9 cm

Nurse Eve prepares to perform light palpation. How is light palpation performed?
a- By indenting the skin ½” to ¾” (1.3 to 1.9 cm).
b- By indenting the skin 1″ to 2″ (2.5 to 5 cm).
c- By indenting the skin 1″, using both hands.
d- By indenting the skin 1″ and then releasing the pressure quickly.

Answer A.
To perform light palpation, the nurse indents the client’s skin ½” to ¾”, using the tips and pads of the fingers.
The nurse indents the skin approximately 1½” (3.8 cm) when performing deep palpation.
The nurse indents the skin 1″ and then releases the pressure quickly when eliciting rebound tenderness.

Nurse Beth correctly identifies which of the following as belonging to the dorsal cavity.. Vertebral canal

Nurse Beth correctly identifies which of the following as belonging to the dorsal cavity?
a- Mediastinum.
b- Mouth.
c- Vertebral canal.
d- Reproductive organs.

Answer C.
The dorsal cavity is divided into the cranial (skull) and vertebral canal (spinal cavity).
The mediastinum and reproductive organs are located in the ventral cavity.
The mouth is located in the oral cavity.

The abdominal cavity is a large space in the middle of the body, above which there is a chest cavity that contains the heart, lungs, trachea and esophagus.
The cavities, in mammalian and human animals, separate the diaphragm muscle that helps in breathing. In the rest of the vertebrates, the cavities are connected without a break.
The members of the thoracic cavity are surrounded by the thoracic cage that protects them, while the members of the abdominal cavity of the back hide the vertebrae and the layers of muscle and skin from all sides: front, back and sides.
The abdominal cavity contains many important organs that are the bulk of the digestive system, also the urinary system and the reproductive system and other organs.
The organs of the gastrointestinal tract are located in the abdominal cavity: the stomach, in the upper left side of the cavity, which resembles a flexible cylindrical sac that folds from the right and opens at first the esophagus and at the end of the intestine begins.
The stomach is constantly moving and the food is mixed with its digestive system and turned into a heavy liquid.
The liver is located on the right side of the abdominal cavity under the diaphragm directly, a large member red color is composed of two lobes, one large on the right and the other small on the left.
The entire urinary tract is located in the abdominal cavity. The kidneys are located in the dorsal part of the cavity, under the digestive system and protected by a cushion of dorsal tissues and muscles.
The kidneys draw harmful substances from the blood in the form of urine, which is transferred by the ureters (two tubes) to the bladder.
The bladder is a round sac located at the bottom of the abdominal cavity, and the urine is stored until it is discharged outside the body by urination.
Another member is the spleen and is located behind the stomach, and the color is light red, which stores a quantity of blood to benefit the body when needed.
The reproductive system includes ovarian females and ovarian and uterine ducts that are enlarged during pregnancy and fill a large space in the abdominal cavity. In males, the testicles are located outside the abdominal cavity, and their channels and some helper glands are located at the bottom of the cavity.

Nurse Arthur is assessing a 47-year-old client who has come to the physician’s office for his annual physical.. increasing loss of muscle tone

Nurse Arthur is assessing a 47-year-old client who has come to the physician’s office for his annual physical.
One of the first physical signs of aging is:
a- having more frequent aches and pains.
b- failing eyesight, especially close vision.
c- increasing loss of muscle tone.
d- accepting limitations while developing assets.

Answer C.
A pleural friction rub, heard in the lateral portion of the lungs during both inspiration and expiration, produces a squeaking or grating sound.
Other abnormal sounds may clear with coughing, but pleural friction rubs don’t.

Signs of muscle loss:

1- Tension and difficulty performing exercise:
You may feel that your exercise is more difficult and you may not want to do it, as you may notice that your strength is less.

2- Slow down during daily activities:
Low muscle mass leads to impaired body function when performing normal daily activities due to lack of energy and over-training.

3- Do not lose fat in your body:
If you lose weight, but your body fat remains the same, it may be a sign of muscle loss instead of fat.

4- Rapid weight loss:
Losing weight requires a long period of time and patience, as a person should lose only one kilogram a week.

Which statement regarding heart sounds is correct.. S1 is loudest at the apex, and S2 is loudest at the base

Which statement regarding heart sounds is correct?
a- S1 and S2 sound equally loud over the entire cardiac area.
b- S1 and S2 sound fainter at the apex.
c- S1 and S2 sound fainter at the base.
d- S1 is loudest at the apex, and S2 is loudest at the base.

Answer D.
The S1 sound - the “lub” sound - is loudest at the apex of the heart.
It sounds longer, lower, and louder there than the S2 sounds.
The S2 - the “dub” sound - is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.

The sounds of heart are the noise caused by the heartbeat and blood flow.
Specifically, the sounds reflect the disturbances that arise in the heart valves if they are suddenly closed.
Your doctor may usually use medical speakers to listen to these unique and distinctive sounds that provide important audio and data related to the condition of the heart.

Relationship between heart sounds and heart pumping:
When listening to the heart using the medical earpiece, the examiner does not hear the valve opening because it is a relatively slow process and does not cause any noise to the normal state.
However, when the valves are closed, their flasks and surrounding liquids are vibrated under the influence of the resulting pressure variations causing a sound that moves in all directions through the chest wall.
When the ventricles contract, the examiner first hears the sound of the Tricuspid valve and the mitral valve, which is a relatively low melody and is known as the first heart sound (S1), which is the first sound of the heart. -dub.
When the pulmonary valve and the aorta vulve are closed at the end of the contractions, a relatively quick cap is heard because these valves close quickly and vibrate the surrounding structures for a short time. This sound is called the second heart sound S2. From the sounds of natural heart lub-dub.

Heart Murmurs:
As a result of medical advances in recent decades, early heart disease is diagnosed and treated, so it is very rare to have symptoms of the disease now, school-age children or adolescents. But sometimes there are teenagers with heart holes and symptoms include: "Feeling tired and weak especially after exercise, loss of appetite, and not to increase weight and difficulty breathing." For infants and in the case of a small hole, there is no symptoms, and the development of the child And breastfeeding is normal, and is often discovered by chance through a routine examination of the child, where strange sounds are heard on the heart's natural voice and these sounds are called heart pressure.

Nurse Gem is auscultating a client’s chest. differentiate a pleural friction rub from other abnormal breath sounds.. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound

Nurse Gem is auscultating a client’s chest.
How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?
a- A rub occurs during expiration only and produces a light, popping, musical noise.
b- A rub occurs during inspiration only and may be heard anywhere.
c- A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.
d- A rub occurs during inspiration only and clears with coughing.

Answer C.
The nurse should systematically assess all areas of the abdomen, if time and the client’s condition permit, concluding with the symptomatic area.
Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.

Nurse Celia prepares to palpate a client’s maxillary sinuses. For this procedure.. Below the cheekbones

Nurse Celia prepares to palpate a client’s maxillary sinuses. For this procedure, where should the nurse place the hands?
a. On the bridge of the nose
b. Below the eyebrows
c. Below the cheekbones
d. Over the temporal area

Answer C.
An adult’s bladder may not be palpable. If it is palpable, it usually is firm, smooth, and located 1″ to 2″ (2.5 to 5 cm) above the symphysis pubis.

A child with rheumatic fever must have his heart rate measured while awake and while sleeping.. To ensure that the child can’t consciously raise or lower the heart rate

A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?
a. To obtain a heart rate that isn’t affected by medication
b. To eliminate interference from the jerky movements of chorea
c. To ensure that the child can’t consciously raise or lower the heart rate
d. To compensate for the effects of activity on the heart rate

Answer C.
To palpate the maxillary sinuses, the nurse places the hands on either side of the client’s nose below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places the thumb just above the client’s eye under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

Nurse Bing prepares to perform an otoscopic examination on an adult.. lobule down and back

Nurse Bing prepares to perform an otoscopic examination on an adult. For proper visualization, the nurse should position the client’s ear by pulling the:
a. lobule down and forward
b. helix up and back
c. helix up and forward
d. lobule down and back

Answer D.
Tachycardia may be a sign of heart failure. Mild tachycardia is more easily detected during sleep than during the day, when activity can cause an increase in heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin, exert their influence both day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. However, it doesn’t affect pulse because the child would be sitting quietly and not involved in purposeful movement. A 10-year-old child is unlikely to be able to consciously raise or lower his heart rate.

Nurse Cora must assess a client’s splinted extremity for neurovascular damage.. Move the client’s fingers or toes to test movement

Nurse Cora must assess a client’s splinted extremity for neurovascular damage. What should she do?
a. Assess extremities, ensuring that the extremity with the splint feels cooler than the unsplinted extremities
b. Move the client’s fingers or toes to test movement
c. Compare the capillary refill of each extremity, making sure it’s the same bilaterally
d. Be aware that edema and pulse checks aren’t part of the neurovascular assessment

Answer B.
To perform an otoscopic examination on an adult, the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the helix and pulls it down to straighten the ear canal. Pulling the lobule in any direction wouldn’t straighten the ear canal for visualization.

All of the following components may be part of a client’s medical record.. Laboratory test results

All of the following components may be part of a client’s medical record. Which one is the major source of subjective data about the client’s health status
a. Health history
b. Physical findings
c. Laboratory test results
d. Radiologic findings

Answer C.
During the complete neurovascular check, extremities should be compared; for example, compare the capillary refill of each extremity. Capillary refill should be the same bilaterally. Extremities should be equally warm. Movement should be checked by having the client move his own fingers and toes. Edema and pulse checks are part of a neurovascular assessment.

Nurse Reese is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include.. coma or seizures

Nurse Reese is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
a. coma or seizures
b. sunken eyeballs and poor skin turgor
c. increased heart rate with hypotension
d. thirst or confusion

Answer A.
Only the health history provides subjective data. Physical findings, laboratory test results, and radiologic findings are examples of objective data.

When examining a client with abdominal pain, nurse Bea should assess.. the symptomatic quadrant either second or third

When examining a client with abdominal pain, nurse Bea should assess:
a. any quadrant first
b. the symptomatic quadrant first
c. the symptomatic quadrant last
d. the symptomatic quadrant either second or third

Answer D.
Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs.

Tachycardia can result from.. fear, pain, or anger

Tachycardia can result from:
a. vagal stimulation
b. vomiting, anger, or suctioning
c. fear, pain, or anger
d. stress, pain, or vomiting

Answer C.
Increases in heart rate (tachycardia) can stem from fear, anger, or pain. Decreases in heart rate (bradycardia) can stem from vomiting, suctioning (causing vagal nerve stimulation), or certain medications.

Nurse Venice prepares to auscultate a client’s carotid arteries for bruits.. use the bell of the stethoscope

Nurse Venice prepares to auscultate a client’s carotid arteries for bruits. For this procedure, the nurse should:
a. have the client inhale during auscultation
b. palpate the radial artery during auscultation
c. use the bell of the stethoscope
d. use the diaphragm of the stethoscope

Answer C.
With the client holding his breath, the nurse uses the bell of the stethoscope to auscultate the carotid arteries for bruits. Having the client inhale would interfere with sound detection. Palpating the radial artery wouldn’t yield significant information and could interfere with the nurse’s ability to listen without interruptions or distractions. The nurse uses the diaphragm of the stethoscope to detect high-pitched sounds, such as breath and bowel sounds.

To evaluate a client’s cerebellar function, nurse Tanya should ask.. Do you have any problems with balance

To evaluate a client’s cerebellar function, nurse Tanya should ask:
a. Do you have any problems with balance
b. Do you have any difficulty speaking
c. Do you have any trouble swallowing food or fluids
d. Have you noticed any changes in muscle strength

Answer A.
To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help evaluate the motor system.

When performing an abdominal assessment, nurse Roger should follow which examination sequence.. Inspection, auscultation, percussion, and palpation

When performing an abdominal assessment, nurse Roger should follow which examination sequence?
a. Inspection, auscultation, percussion, and palpation
b. Inspection, auscultation, palpation, and percussion
c. Inspection, percussion, palpation, and auscultation
d. Inspection, palpation, percussion, and auscultation

Answer A.
The correct sequence for abdominal assessment is inspection, auscultation, percussion, and palpation because this sequence prevents altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation.