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Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. The inferior vena cava does not significantly narrow with aging. Varicosities are more commonly due to valve insufficiency in the veins rather than vena cava narrowing.

Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. Venous insufficiency is common in older adults, but it is primarily due to valve dysfunction and prolonged venous pressure rather than atrophy of calf veins.

Hormonal changes causing vasodilation and a resulting drop in blood pressure. While some hormonal changes occur with aging, they do not typically lead to significant vasodilation. In fact, the loss of vascular elasticity and autonomic dysfunction can contribute to postural hypotension, but not a generalized drop in blood pressure.

Auscultation. Auscultation involves listening to internal body sounds, usually with a stethoscope, such as heart, lung, or bowel sounds. It is not used for assessing the radial pulse.

Percussion. Percussion is the technique of tapping on body surfaces to assess underlying structures, such as detecting fluid in the lungs or assessing organ size. It is not used to assess pulses.

Inspection. Inspection involves visually examining the patient for abnormalities such as skin color, swelling, or deformities. It does not provide information about pulse rate or rhythm.

Temperature, pulse, respirations, BP. While these are standard vital signs, they do not include oxygen saturation or pain level, both of which are critical in a patient with chest pain.

Temperature, pulse, respirations, BP, pain. Pain is an essential assessment, especially for chest pain, but oxygen saturation should also be measured to assess for hypoxia, which can contribute to cardiac symptoms.

BP, respirations, temperature, pulse. This option omits both oxygen saturation and pain level, which are essential in evaluating cardiac and respiratory function in a patient presenting with chest pain.

Irritating cough. Opioid agonists do not typically cause an irritating cough. In fact, opioids like codeine are used as antitussives to suppress cough reflexes.

Tachypnea. Opioids depress the central nervous system, leading to respiratory depression rather than an increased respiratory rate (tachypnea). The nurse should monitor for bradypnea instead.

Hypertension. Opioids commonly cause hypotension due to vasodilation and central nervous system depression. Hypertension is not a typical adverse effect.

Elevated blood pressure. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure by relaxing blood vessels. It does not cause an increase in blood pressure.

Intestinal ileus. Lisinopril does not typically cause an intestinal ileus. This condition is more commonly associated with medications that affect gastrointestinal motility, such as opioids or anticholinergics.

Delirium. While some medications can cause delirium, Lisinopril does not have central nervous system effects that would commonly lead to confusion or altered mental status.

200/92. This format does not include the muffling point (Phase IV), which is important in some clinical settings, such as in critically ill patients or those with vascular diseases.

100/200/92. This order is incorrect because the systolic pressure should always be listed first, followed by the diastolic components.

200/100. This format omits the point at which sounds completely disappear (Phase V), which is the true diastolic pressure in most cases. However, in some individuals, particularly those with conditions like aortic regurgitation, the muffling point may be recorded as an additional reading.

Family members report that pain has subsided. Pain is a subjective experience, and the patient's own report is the most reliable indicator of pain relief, not the observations of family members.

Vital signs have returned to baseline. While pain can affect vital signs, such as increasing heart rate or blood pressure, their return to normal does not necessarily indicate adequate pain relief. Some patients may still experience significant pain despite stable vital signs.

Body language is incongruent with reports of pain relief. Nonverbal cues can be helpful in assessing pain, but they should not override the patient’s self-reported pain level, which is the most accurate measure.

Ask the client to take deep breaths. Deep breathing can help relax the anal sphincter, but if resistance is already encountered, forcing the thermometer further could cause injury.

Remove the thermometer and reinsert more forcefully. Forcing the thermometer can cause damage to the rectal mucosa, leading to pain, bleeding, or even perforation.

Apply mild pressure to advance. Any resistance suggests a possible obstruction, such as stool or anatomical issues. Applying pressure could cause harm, so the thermometer should not be advanced further.