A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

Decreased BP during orthostatic blood pressure measurement.

Grade 3 systolic murmur auscultated at the pulmonic site.

3+ carotid pulse volume bilaterally.

Positive jugular vein distention (JVD) bilaterally.

Answer and Explanation

The Correct Answer is A

A. Decreased BP during orthostatic blood pressure measurement: Syncope (fainting) often results from decreased blood flow to the brain. Orthostatic hypotension (a drop in blood pressure upon standing) can lead to syncope.

B. Grade 3 systolic murmur auscultated at the pulmonic site: A systolic murmur may indicate valvular or cardiac issues but is not directly related to syncope.

C. 3+ carotid pulse volume bilaterally: Carotid pulse volume assessment helps evaluate blood flow to the brain. Normal carotid pulses are important for preventing syncope

D. Positive jugular vein distention (JVD) bilaterally: JVD is associated with heart failure or fluid overload. While it may not directly cause syncope, it can contribute to overall cardiovascular instability.

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Correct Answer is C

Explanation

A. Diminished appetite: While this can be a symptom of various conditions, it's not a direct indicator for a bone density screening.

B. Lower body mass index (BMI): A lower BMI can increase the risk of osteoporosis, but it's not a definitive sign requiring immediate bone density screening.

C. Decreased height: Losing height as an adult can be a sign of vertebral fractures caused by osteoporosis. This is a significant finding that warrants a bone density screening to assess bone mineral density.

D. 15-pound weight loss: Sudden or unexplained weight loss can be a concern, but it doesn't directly suggest the need for a bone density test unless accompanied by other risk factors.

A. Crackles. B. Vesicular. C. Bronchial. D. Wheezes.

Correct Answer is B

Explanation

A.Crackles: Crackles, also known as rales, are abnormal lung sounds that can indicate conditions such as pneumonia, pulmonary edema, or interstitial lung disease. They are often described as fine or coarse, and they may be heard during inspiration, expiration, or both. Crackles are typically heard over areas of fluid-filled alveoli or small airways.

B. Vesicular. These sounds are typically heard over most of the lung fields and are associated with normal airflow through smaller airways.

C. Bronchial: Bronchial breath sounds are typically heard over the trachea and mainstem bronchi. These sounds are louder and higher in pitch compared to vesicular sounds, with a shorter inspiratory phase and a longer expiratory phase. Hearing bronchial sounds over peripheral lung fields would suggest consolidation or compression of lung tissue, such as in pneumonia or atelectasis.

D. Wheezes: Wheezes are high-pitched, musical sounds heard primarily during expiration. They are typically associated with narrowed airways, such as in asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. Wheezes may be heard over the lung fields if there is widespread airway obstruction or bronchoconstriction.

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A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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