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 ["9"]

Explanation

To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:

Heart rate: 150 beats/minute --> Score of 2.
Respiratory effort: Vigorous cry present --> Score of 2.
Muscle tone: Good muscle tone with total flexion --> Score of 2.
Reflex irritability: Quick reflex irritability noted --> Score of 2.
Color: Dusky and cyanotic skin color --> Score of 1.

Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9

Therefore, the Apgar score for this infant is 9.

A. Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity. B. Instruct the PN to measure the client's waist circumference every 8 hours to assess for changes. C. Tell the PN that this assessment technique should be performed by the nurse. D. Review the measurement obtained by the PN and compare with ideal measurements for this client.

Correct Answer is D

Explanation

A. Advise the PN that waist circumference measurements are valuable to assess fluid retention but not obesity. Waist circumference is actually a valuable measure for assessing abdominal obesity, which is an important factor in health, independent of BMI. It helps screen for health risks related to overweight and obesity, such as heart disease and type 2 diabetes. Therefore, this option is incorrect.

B. Instruct the PN to measure the client’s waist circumference every 8 hours to assess for changes. Measuring waist circumference does not require frequent assessments like every 8 hours. It’s a simple and inexpensive measurement that provides valuable information about abdominal fat distribution. However, such frequent measurements are unnecessary and impractical for assessing obesity-related risks.

C. Tell the PN that this assessment technique should be performed by the nurse. Waist circumference measurements can be performed by practical nurses (PNs) and other healthcare providers. It’s a straightforward technique that doesn’t require specialized training. Therefore, this option is incorrect.

D. Review the measurement obtained by the PN and compare with ideal measurements for this client. This is the most appropriate action. The nurse should review the PNs measurement of the client’s waist circumference and compare it to established guidelines. Generally, a waist circumference greater than 35 inches for women or greater than 40 inches for men indicates increased risk of obesity-related health problems.

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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

Correct Answer is ["9"]

Explanation

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

Correct Answer is D

Explanation

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