A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

Decreased BP during orthostatic blood pressure measurement.

Grade 3 systolic murmur auscultated at the pulmonic site.

3+ carotid pulse volume bilaterally.

Positive jugular vein distention (JVD) bilaterally.

Answer and Explanation

The Correct Answer is A

A. Decreased BP during orthostatic blood pressure measurement: Syncope (fainting) often results from decreased blood flow to the brain. Orthostatic hypotension (a drop in blood pressure upon standing) can lead to syncope.

B. Grade 3 systolic murmur auscultated at the pulmonic site: A systolic murmur may indicate valvular or cardiac issues but is not directly related to syncope.

C. 3+ carotid pulse volume bilaterally: Carotid pulse volume assessment helps evaluate blood flow to the brain. Normal carotid pulses are important for preventing syncope

D. Positive jugular vein distention (JVD) bilaterally: JVD is associated with heart failure or fluid overload. While it may not directly cause syncope, it can contribute to overall cardiovascular instability.

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Correct Answer is C

Explanation

A. Capillary refill both feet greater than 3 seconds: Delayed capillary refill indicates poor peripheral perfusion but does not directly correlate with swelling.

B. Pedal pulses weak and thready: Weak and thready pedal pulses indicate poor arterial circulation but do not directly confirm swelling.

C. 2+ pitting edema of ankles bilaterally: Pitting edema is a direct indicator of swelling. A 2+ pitting edema specifically confirms the presence of significant fluid accumulation in the tissues of the ankles.

D. Positive Homan's sign bilaterally: A positive Homan's sign can indicate deep vein thrombosis (DVT), which can be associated with swelling but is not a definitive indicator of chronic swelling.

A. Dimpled area above anus. B. Flap of tissue at sphincter. C. Hypotonic tone of the anal sphincter. D. Increased pigmentation and coarse skin.

Correct Answer is D

Explanation

A. Dimpled area above anus: This can be a sign of a pilonidal cyst, a condition where hair follicles become embedded under the skin.

B. Flap of tissue at sphincter: This could indicate haemorrhoids, swollen veins in the anus and rectum.

C. Hypotonic tone of the anal sphincter: Weak anal sphincter tone can lead to faecal incontinence.

D. Increased pigmentation and coarse skin: This is a normal finding, especially in adults. The perianal area can have a darker colour and thicker skin texture compared to other areas

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A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

Which assessment finding supports the client statement, "My feet swell all the time?"

Correct Answer is C

Explanation

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Correct Answer is D

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