After taking the vital signs of a client, the nurse notes the client has a high systolic blood pressure reading. Which factors should the nurse include when explaining the possible cause of this increase? Select all that apply.

Caffeine intake

Post meal

Stress

Drinking a glass of water

Time of day

Answer and Explanation

Correct Answer : A,C,E

A. Caffeine intake: Can cause a temporary increase in blood pressure due to its stimulant effects.

B. Post meal: While eating can cause temporary changes in blood pressure, it is less likely to be a significant factor compared to other causes.

C. Stress: Can lead to temporary increases in blood pressure due to the body's stress response.

D. Drinking a glass of water: Typically does not significantly affect blood pressure unless there is an underlying issue such as dehydration.

E. Time of day: Blood pressure can naturally vary throughout the day, often being higher in the morning and lower in the evening.

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Correct Answer is D

Explanation

A. Dextrocardia is a condition where the heart is located on the right side of the chest and does not typically cause crackles in the lungs.

B. Hypertension may lead to cardiovascular complications but is not directly associated with crackles in the lungs.

C. Palpitations are related to sensations of irregular or rapid heartbeats, not crackles in the lungs.

D. Fine crackles in the lungs are often associated with left-sided heart failure due to fluid accumulation in the lungs from compromised cardiac function.

A. Second or third intercostal space at the left sternal border B. The second intercostal space at the right sternal border C. Fifth intercostal space near the left midclavicular line D. Third intercostal space at the left sternal border

Correct Answer is A

Explanation

Rationale:
A. Second or third intercostal space at the left sternal border: Erb's point is located here, and it's a key area for listening to heart sounds, particularly the aortic and pulmonic valves.

B. The second intercostal space at the right sternal border: This area is typically used to auscultate the aortic valve.

C. Fifth intercostal space near the left midclavicular line: This area is used to auscultate the mitral valve, not Erb's point.

D. Third intercostal space at the left sternal border: This is the location for listening to the pulmonic valve, not Erb's point.

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After taking the vital signs of a client, the nurse notes the client has a high systolic blood pressure reading. Which factors should the nurse include when explaining the possible cause of this increase? Select all that apply.

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Naxlex Comprehensive Predictor Exams

While conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. This finding is most likely a manifestation of which problem?

Correct Answer is D

Explanation

The traditional areas of auscultation of heart sounds include Erb's point, which is located at?

Correct Answer is A

Explanation

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