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 A

Explanation

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

A. Inspect for pedal edema. B. Obtain a blood pressure. C. Listen to fetal heart rate. D. Ask for a 24-hour diet recall.

Correct Answer is B

Explanation

A. Inspect for pedal edema. While pedal edema can be a sign of preeclampsia, obtaining blood pressure is a more immediate and crucial assessment.

B. Obtain a blood pressure. This is the correct next step, as rapid weight gain and nausea/vomiting can be symptoms of preeclampsia, which is often accompanied by hypertension.

C. Listen to foetal heart rate. This is important but secondary to assessing the mother's condition, especially when preeclampsia is suspected.

D. Ask for a 24-hour diet recall. This might be relevant for nutritional assessment but is not the priority when preeclampsia is suspected.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

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Explanation

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Correct Answer is B

Explanation

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