The nurse notices a colleague is preparing to check the blood pressure of a patient who is sitting with his legs crossed. The nurse knows that this will:
a. yield a falsely low blood pressure.
b. have no effect on the blood pressure reading.
c. produces an auscultatory gap.
d. yield a falsely...
The nurse notices a colleague is preparing to check the blood pressure of a patient who is sitting with
his legs crossed. The nurse knows that this will:
a. yield a falsely low blood pressure.
b. have no effect on the blood pressure reading.
c. produces an auscultatory gap.
d. yield a falsely high blood pressure. - ANSWERD
(Blood pressure increases when legs are crossed and care should be taken to ensure that feet are flat
on the floor to avoid a *false high blood pressure.)
Which activity illustrates the concept of *primary prevention*?
a. exercising three times a week
b. monthly breast self-examination
c. education about living with asthma
d. colonoscopy after age of 50 - ANSWERA
(a primary prevention aimed at preventing the individual from developing an illness.)
A 75- y/o man reports he stopped playing cards with his friends because, over time, he noticed their
voices began to sound mumbled. How does the nurse explain the possible cause of this change?
a. sudden low-frequency hearing loss
b. damage to the middle ear from ear infections
c. gradual high-frequency hearing loss
,d. lack of earwax in the outer ear - ANSWERC
(High-frequency hearing loss, or *presbycusis*, can occur as we age. It involves problems w]usually
with discerning certain constant sounds like F, S, T and Z. Vowels are easier to hear for a person with
high-frequency loss. Not being able to hear certain letter sounds may make speech sound mumbled.
Older adults can become disheartened or frustrated when not being able to make out speech
adequately and can become withdrawn. The issue is not related to a low-frequency hearing loss, lack
of earwax, or ear infections.)
A nurse is assessing a patient who complains of "awful" hip pain after suffering a fracture and rates it
as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain?
(Select all that apply)
a. depression
b. tachycardia
c. increased blood pressure
d. loss of weight and appetite - ANSWERCB
(Tachycardia and increased bp are associated with the sympathetic nervous system response that
occurs in acute pain. Depression and loss of appetite are more associated with chronic pain.)
A patient is describing his symptoms to the nurse. Which of these statements reflects a description of
the aggravating factors for his symptoms?
a. "It is a sharp, burning pain in my stomach."
b. "When I sit down to use the computer, it gets worse."
c. "I think this pain is telling me that something bad is wrong with me."
d. "I also have the sweats and nausea when I feel this pain." - ANSWERB
(Aggravating factors are things the patient does or that happen to the patient that make the
symptom worse or more pronounced. This answer is the only one that was *associated with a
symptom.*)
A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when
calling her name, but she remains drowsy during the conversation. The best description of this
patient's level of consciousness would be:
, a. semialert
b. obtunded
c. stuporous
d. lethargic - ANSWERD
(When a patient is lethargic, they may be drowsy but awaken easily to stimulation. They can answer
questions and follow commands. A patient who is obtunded is difficult to arouse and needs constant
stimulation in order to keep them awake. They may answer basic, direct questions. Wen a patient is
stuporous, they require vigorous stimulation to arouse and will not be able to answer questions to
follow commands. Semialert is not a term used in a mental health assessment.)
During shift report, a nurse learns that a patient has a *macular rash*. As the nurse inspects the
patient's skin, what finding will confirm the rash?
a. elevated, firm, well-defined lesions less than 1 cm in diameter
b. depressed, firm, or scaly, rough lesions greater than 1 cm in diameter.
c. flat, well-defined, small lesions less than 1 cm in diameter
d. elevated fluid-filled lesions less than 1 cm in diameter - ANSWERC
(A macule is a lesion that is flat, circumscribed, less than 1cm. An elevated lesion would be a
*papule*. An elevated, fluid-filled lesion is a vesicle.)
When assessing the severity of a patient's pain, which question by the nurse is appropriate?
a. "What makes your pain better or worse?"
b. "How much pain do you have now?"
c. "how does pain limit your activities?"
d. "What does your pain feel like?" - ANSWERB
(In rating the severity of the pain, you want to determine how strong or intense it is. The nurse can
ask them how much pain they are having often using some type of rating scale.)
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