A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

Apply the largest cuff available.

Place the arm above the level of the client's heart.

Deflate the cuff quickly.

Use the palpatory method to determine blood pressure.

Answer and Explanation

The Correct Answer is D

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.

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Correct Answer is B

Explanation

A. Incorrect. Absence seizures typically do not have an aura. They are characterized by a sudden and brief loss of awareness without warning.

B. Correct. Absence seizures often involve a brief period of staring and decreased responsiveness. They can indeed be mistaken for daydreaming, as they are not as dramatic as other types of seizures.

C. Incorrect. Absence seizures are usually very brief, lasting only a few seconds (often less than 10 seconds), rather than 30 to 60 seconds.

D. Incorrect. Absence seizures have a sudden and abrupt onset, not a gradual one. They occur without warning and without a preceding aura.

A. Educate the family to avoid sharing personal belongings. B. Ensure the state health department has been notified. C. Administer antitoxin. D. Assess for skin necrosis.

Correct Answer is B

Explanation

A. Lyme disease is primarily transmitted through ticks.

B. Lyme disease is a communicable disease of public concern and hence reportable

C. Incorrect. Antitoxin is not used for treating Lyme disease. Lyme disease is caused by a bacterium, not a toxin.

D. Incorrect. Skin necrosis is not a common manifestation of Lyme disease. The primary symptoms include fever, fatigue, headache, and a characteristic skin rash known as erythema migrans.

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A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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