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. Allow the client to compose herself then change the subject.

This response allows the client some time to regain composure, which can be helpful. However, abruptly changing the subject may make the client feel dismissed or unheard. It's essential to address the emotional response with sensitivity.

B. "Why don't I come back in a few minutes after you are more composed."

While this response acknowledges the client's emotional state, it may unintentionally communicate a lack of availability or willingness to support the client in that moment. It's important for the nurse to offer support and empathy immediately rather than suggesting a delay.

C. "I'm so sorry that I made you cry. I didn't mean to upset you."

This response acknowledges the client's emotional response and expresses empathy, which is a crucial aspect of providing patient-centered care. However, it's important to avoid taking personal responsibility for the client's emotional reaction, as it may not have been caused solely by the nurse's questions.

D. Offer a tissue and sit quietly until the crying subsides.

This response demonstrates empathy and support by providing a tissue and offering a non-verbal gesture of comfort. Sitting quietly allows the client the space to express her emotions while feeling supported by the nurse's presence.

A. Determine degree of skin elasticity. B. Measure muscle size and strength. C. Inspect appearance of the spine. D. Note 24-hour fluid intake and output.

Correct Answer is B

Explanation

A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.

B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.

C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.

D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.

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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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