The nurse notes that there is a difference in a patient's blood pressure (BP) and heart rate (HR) when the patient changes position from supine to standing. The differences are a decrease of 20 mm Hg in systolic BP, a decrease of 10 mm Hg in diastolic BP, and an increase in the HR of 20 beats/minute.
Which interpretation would the nurse make about the patient's condition?
Hypertensive crisis.
An auscultatory gap.
Resistant hypertension.
Enlarged lymph nodes.
The Correct Answer is B
Choice A rationale:
Hypertensive crisis is characterized by severely elevated blood pressure, usually above 180/120 mm Hg. The given differences in blood pressure (a decrease of 20 mm Hg in systolic BP) do not indicate hypertensive crisis.
Choice B rationale:
An auscultatory gap refers to a temporary disappearance of sounds normally heard over the brachial artery during blood pressure measurement. This phenomenon can lead to inaccurate readings and might cause a delay in recognizing the true blood pressure values. In this case, the decrease in systolic BP when changing positions indicates the presence of an auscultatory gap, requiring the nurse to be vigilant during blood pressure measurements.
Choice C rationale:
Resistant hypertension is a term used when blood pressure remains above goal despite concurrent use of three antihypertensive agents of different classes. The given scenario does not indicate resistant hypertension but rather suggests a technical issue during blood pressure measurement due to the auscultatory gap.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Thrombus formation is a later stage event in coronary artery disease (CAD) and occurs after the development of fatty streaks. Thrombus formation usually happens due to the rupture of atherosclerotic plaques, leading to platelet aggregation and clot formation.
Choice B rationale:
Formation of fibrous plaque in the endothelium is a progression that occurs after the initial development of fatty streaks. Fibrous plaques are formed as a response to the inflammation caused by fatty deposits. They are more stable than fatty streaks but can still lead to narrowing of the arteries.
Choice C rationale:
Reduction of blood flow through the coronary arteries is a consequence of atherosclerosis, which occurs after the initial development of fatty streaks. As the fatty deposits accumulate, they narrow the arteries, leading to reduced blood flow. However, this is not the initial change that makes patients susceptible to CAD.
Choice D rationale:
Development of fatty streaks in the smooth muscles of the endothelium is the initial change that occurs in the development of atherosclerosis, making patients susceptible to coronary artery disease. Fatty streaks are composed of lipid-laden macrophages and smooth muscle cells. Over time, these fatty streaks can progress into fibrous plaques and eventually lead to complications such as thrombus formation and reduced blood flow.
Correct Answer is C
Explanation
The correct answer is choice C. Uses an alcohol-based mouthwash twice a day.
Choice A rationale:
Drinking 14 glasses of water daily is generally beneficial as it helps maintain hydration and supports overall health. However, it is important to balance fluid intake to avoid overhydration.
Choice B rationale:
Shaving with an electric razor is recommended for patients with thrombocytopenia because it reduces the risk of cuts and bleeding compared to using a traditional razor.
Choice C rationale:
Using an alcohol-based mouthwash can cause dryness and irritation of the oral mucosa, which can lead to bleeding, especially in patients with thrombocytopenia. It is better to use a non-alcoholic mouthwash.
Choice D rationale:
Brushing teeth with a soft-bristle toothbrush is advised to minimize the risk of gum bleeding and maintain oral hygiene.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today