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)

dialysis shunt.

2-year-old hand amputation.

previous mastectomy.

patent IV line.

Answer and Explanation

Correct Answer : A,C

A.   A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B.   A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C.   A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D.   A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.

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Correct Answer is ["A","B","C","D"]

Explanation

A. A significant drop in blood pressure when standing (typically greater than 20 mm Hg systolic or 10 mm Hg diastolic) is a hallmark of orthostatic hypotension.
B. Dizziness upon standing is a classic symptom of orthostatic hypotension due to decreased blood flow to the brain.
C. Blurred vision can also result from decreased blood flow and is a common symptom of orthostatic hypotension.
D. Syncope (fainting) can occur as a result of orthostatic hypotension when the brain does not receive enough oxygenated blood due to the drop in blood pressure.

A. the eyes move in a normal coordinated manner. B. the pupils dilate when focusing on the object. C. there is blinking while trying to focus on the object. D. the pupils constrict focusing on the object.

Correct Answer is A

Explanation

A. Checking for normal, coordinated eye movement is key when assessing extraocular movements, which should be smooth and symmetric.
B. Pupillary dilation occurs under specific circumstances, such as low light, not necessarily when focusing on an object.
C. Blinking is a normal reflex but not a primary indicator when assessing extraocular movements.
D. Pupillary constriction is a separate function of the pupillary light reflex and not directly associated with extraocular movements.

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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)

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["A","B","C","D"]

Explanation

When checking extraocular movements, the nurse asks the patient to follow an object as it is moved into different positions and watch to see if

Correct Answer is A

Explanation

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)

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