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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is B. Hypertonic saltwater.

Choice A rationale: Hypotonic saltwater would not cause significant fluid shifts into the alveoli. Instead, it would cause cells to swell due to the lower concentration of solutes outside the cells.

Choice B rationale: Hypertonic saltwater causes fluid to be drawn from the vascular space into the alveoli due to the higher concentration of solutes in the water compared to the body's cells. This can impair alveolar ventilation and result in hypoxia.

Choice C rationale: Hypotonic freshwater would cause cells to swell and potentially burst due to the lower concentration of solutes outside the cells, but it would not specifically cause fluid to be drawn into the alveoli.

Choice D rationale: Hypertonic freshwater is not a common classification for drowning water. Freshwater is typically hypotonic compared to body fluids, and it would not cause the same fluid shift as hypertonic saltwater.

A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.

Correct Answer is C

Explanation

Choice A rationale:

Metabolic acidosis is characterized by low blood pH and low bicarbonate ion levels. In this case, the patient has a high bicarbonate ion level (25 mEq/L), indicating a compensatory response to respiratory acidosis. Metabolic alkalosis, on the other hand, would present with high pH and high bicarbonate ion levels.

Choice B rationale:

Metabolic alkalosis is characterized by high blood pH and high bicarbonate ion levels. The patient's bicarbonate ion level (25 mEq/L) is within the normal range, and the low pH and high PaCO2 (49 mm Hg) indicate respiratory acidosis, not metabolic alkalosis.

Choice C rationale:

Respiratory acidosis is characterized by low blood pH and high partial pressure of carbon dioxide (PaCO2) levels. In this case, the patient has a low pH (7.29) and elevated PaCO2 (49 mm Hg), indicating respiratory acidosis. The elevated bicarbonate ion level (25 mEq/L) is a compensatory response. Respiratory alkalosis would present with high pH and low PaCO2 levels.

Choice D rationale:

Respiratory alkalosis is characterized by high blood pH and low PaCO2 levels. The patient's PaCO2 level is elevated (49 mm Hg), indicating respiratory acidosis, not alkalosis. The low pH (7.29) further supports the diagnosis of respiratory acidosis.

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Naxlex Comprehensive Predictor Exams

In which type of water would a submersion injury cause the patient's fluid to be drawn from the vascular space into the alveoli, impairing alveolar ventilation and resulting in hypoxia?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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