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 D

Explanation

A. Increase fibre in diet and add daily prune juice: Increasing dietary fibre and adding prune juice can help promote bowel movements and relieve constipation. However, this is a long-term solution and might not address any immediate underlying issues.

B. Perform a digital examination for faecal impaction: This invasive procedure can confirm or rule out faecal impaction, which is a potential cause of severe constipation, especially in older adults. However, it's not typically the first step without further assessment.

C. Assess type and frequency of physical activities: Physical activity affects bowel motility. Assessing activity levels can provide insight into one possible cause of constipation. However, this should come after assessing more direct symptoms.

D. Check bowel sounds and abdominal tenderness: This is a non-invasive initial assessment that can provide important information about the client's bowel activity and potential obstructions. It helps determine the next steps for diagnosis and treatment.

A. Ask questions in a vague, nonspecific format. B. Share personal values to put the client at ease. C. Get the most difficult questions over with first. D. Begin with questions that are less sensitive in nature.

Correct Answer is D

Explanation

A. Ask questions in a vague, nonspecific format: Vague questions won't elicit clear answers.

B. Share personal values to put the client at ease: While building rapport is important, sharing personal values might not be necessary.

C. Get the most difficult questions over with first: This can make the client defensive and less likely to be honest.

D. Begin with less sensitive questions: Starting with general questions about lifestyle habits and then gradually transitioning to more specific questions about alcohol and substance use can create a more comfortable environment for open communication

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

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Correct Answer is D

Explanation

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

Correct Answer is D

Explanation

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