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 C
Explanation
Choice A rationale:
Buffers do not excrete weak acids; instead, they help regulate the pH of bodily fluids by preventing drastic changes in acidity or alkalinity.
Choice B rationale:
Buffers do not secrete hydrogen ions. In fact, buffers can either absorb or release hydrogen ions to maintain a stable pH.
Choice C rationale:
To convert strong acids to weak acids is the correct answer. Buffers are substances that can neutralize both acids and bases, helping to maintain a stable pH in a solution. They achieve this by accepting hydrogen ions from strong acids or donating hydrogen ions to strong bases, converting them into weaker acids or bases, respectively.
Choice D rationale:
Buffers do not convert ammonia to ammonium ions. This conversion is a part of the body's acid-base regulation system, but it is not the primary function of buffers.
Correct Answer is D
Explanation
Choice A rationale:
Adequate platelet production does not explain the prolonged bleeding times in von Willebrand disease. These patients often have normal platelet counts, but their platelets do not function properly due to the absence or dysfunction of von Willebrand factor.
Choice B rationale:
Deficiency in intrinsic clotting system factor is not the primary cause of prolonged bleeding times in von Willebrand disease. The deficiency or dysfunction of von Willebrand factor, a protein that helps platelets adhere to the blood vessel walls and clot properly, is the key issue in this disorder.
Choice C rationale:
Impairment of the thrombin fibrinogen reaction does not directly relate to von Willebrand disease. This disorder primarily involves platelet dysfunction and variable factor VIII deficiencies, leading to prolonged bleeding times.
Choice D rationale:
Variable factor VIII deficiencies and platelet dysfunction are characteristic of von Willebrand disease. Factor VIII helps with blood clotting, and its deficiency, along with impaired platelet function, contributes to the prolonged bleeding times in patients with von Willebrand disease.
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