The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

instruct the patient to remain on strict bed rest

provide the patient with additional blankets"

encourage the patent to increase his muscle activity”

offer fluids to the patient if permitted

Answer and Explanation

The Correct Answer is C

A.   Keeping the patient on bed rest is appropriate as it conserves energy and helps prevent further heat loss.
B.   Providing additional blankets is a correct intervention to warm the patient gradually.
C.   Increasing muscle activity is contraindicated because it could cause vasoconstriction and worsen hypothermia, as the body focuses on preserving core temperature.
D.   Offering fluids (if permitted) is correct as hydration can help restore normal body temperature regulation.

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Correct Answer is D

Explanation

A. A murmur or swishing sound does not correspond to the diastolic pressure; it is more indicative of turbulent blood flow.
B. Clear tapping sounds are heard at systolic pressure but do not indicate diastolic pressure.
C. Knocking sounds are associated with systolic pressure, not diastolic.
D. The muffling sound heard after the first Korotkoff sounds indicates the diastolic pressure in children and some adults, which is the correct method for assessing the diastolic reading.

A. gather information from a family member accompanying the patient. B. omit the interview and proceed to a physical examination. C. repeat the questions at the end of the visit to cross check for accuracy of data. D. reassure the patient that forgetfulness is a normal part of the aging process.

Correct Answer is A

Explanation

A. Gathering information from a family member can help obtain a more accurate history, especially when the patient has difficulty recalling specific details due to age-related memory changes.
B. Omitting the interview would lead to incomplete information and potentially delay appropriate care.
C. Repeating the questions may be helpful but may not always yield reliable data if the patient struggles to remember key details.
D. While forgetfulness can be normal with aging, healthcare providers need to ensure accurate information is collected to provide optimal care.

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The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:

Correct Answer is D

Explanation

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

Correct Answer is A

Explanation

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

The nurse taking a blood pressure should:

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

When performing an initial assessment on a patient, which piece of information is of highest priority?

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)