A nurse assesses a client's blood pressure manually. Which technique would be used for this assessment?
Auscultation
Inspection
Palpation
Percussion
The Correct Answer is A
A. Auscultation: When assessing blood pressure manually, the nurse listens for the sounds of Korotkoff using a stethoscope, which is called auscultation. This technique allows the nurse to determine the systolic and diastolic pressures as the blood flow returns to the artery.
B. Inspection: Inspection involves visually examining the patient for signs or symptoms, such as skin color, breathing patterns, or posture. It does not involve listening to or feeling for the sounds associated with blood pressure measurements.
C. Palpation: Palpation involves feeling for pulses or other sensations, but it is not used to assess blood pressure directly. While palpation may be used to estimate systolic pressure by feeling the pulse, it does not allow for accurate measurement of both systolic and diastolic pressures.
D. Percussion: Percussion involves tapping on the body to assess underlying structures, typically to evaluate organ size or detect fluid. It is not used for assessing blood pressure, which requires listening to sounds produced by blood flow.
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Related Questions
Correct Answer is A
Explanation
A. Auscultation: When assessing blood pressure manually, the nurse listens for the sounds of Korotkoff using a stethoscope, which is called auscultation. This technique allows the nurse to determine the systolic and diastolic pressures as the blood flow returns to the artery.
B. Inspection: Inspection involves visually examining the patient for signs or symptoms, such as skin color, breathing patterns, or posture. It does not involve listening to or feeling for the sounds associated with blood pressure measurements.
C. Palpation: Palpation involves feeling for pulses or other sensations, but it is not used to assess blood pressure directly. While palpation may be used to estimate systolic pressure by feeling the pulse, it does not allow for accurate measurement of both systolic and diastolic pressures.
D. Percussion: Percussion involves tapping on the body to assess underlying structures, typically to evaluate organ size or detect fluid. It is not used for assessing blood pressure, which requires listening to sounds produced by blood flow.
Correct Answer is B
Explanation
A. stage 4 pressure injury: A stage 4 pressure injury involves full-thickness skin and tissue loss with exposed bone, tendon, or muscle, which is beyond subcutaneous tissue damage. These wounds may also include undermining or tunneling and carry a high risk for infection.
B. stage 3 pressure injury: Stage 3 pressure injuries involve full-thickness skin loss that extends into the subcutaneous tissue but does not expose bone, tendon, or muscle, aligning with the description of the wound. This stage may also include slough, undermining, or tunneling.
C. stage 2 pressure injury: A stage 2 injury involves partial-thickness skin loss with exposure of the dermis, typically presenting as a shallow open ulcer, not reaching subcutaneous layers. It may also appear as an intact or ruptured serum-filled blister.
D. stage 1 pressure injury: Stage 1 is characterized by non-blanchable erythema of intact skin without any tissue loss or damage to deeper layers.
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