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A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” What is the nurse’s best reply?

“The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”

“The bottom number is the diastolic pressure and reflects the stroke volume of the heart.”

“The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure.”

“The numbers are within normal range and are nothing to worry about.”

Answer and Explanation

The Correct Answer is A

Choice A reason: The systolic pressure (top number) measures arterial pressure during heart contraction, accurately explaining 118/82 mm Hg. This clear, correct definition educates the patient, making it the best reply.

Choice B reason: Diastolic pressure (bottom number) reflects arterial pressure at rest, not stroke volume. Systolic pressure is correctly defined as contraction pressure, so this is incorrect for explaining the numbers.

Choice C reason: Dismissing blood pressure as complex is unhelpful; both numbers matter. Systolic pressure is accurately defined as heart contraction pressure, so this is incorrect for patient education.

Choice D reason: Stating the numbers are normal (118/82 is prehypertension) avoids explaining their meaning. Defining systolic pressure clarifies the reading, so this is incorrect for answering the question.

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Correct Answer is C

Explanation

Choice A reason: Intelligence cannot be assessed in a 3-month-old, as cognitive abilities are not yet developed enough for evaluation. Sucking and grasping are innate behaviors driven by reflexes, not conscious thought, making this an incorrect assessment focus.

Choice B reason: Cerebral cortex function is immature in a 3-month-old, and sucking and grasping are primarily brainstem-mediated reflexes. These actions do not directly assess higher cortical functions like memory or reasoning, making this an incorrect choice.

Choice C reason: Sucking and grasping in a 3-month-old are primitive reflexes (sucking reflex and palmar grasp reflex), mediated by the brainstem. Assessing these evaluates normal neurological development, making this the correct focus of the nurse’s inquiry.

Choice D reason: While sucking involves Cranial Nerves V, VII, IX, and XII, and grasping involves spinal reflexes, the nurse is assessing the presence of these reflexes, not the cranial nerves directly. Reflex assessment is the primary focus, making this less precise.

A. Referred B. Visceral C. Cutaneous D. Neuropathic

Correct Answer is D

Explanation

Choice A reason: Referred pain originates in one area but is felt elsewhere, not due to abnormal impulse processing. Neuropathic pain involves nerve dysfunction, so this is incorrect for the pain type described.

Choice B reason: Visceral pain arises from internal organs, not nerve processing issues. Neuropathic pain results from abnormal peripheral or central nerve activity, so this is incorrect for the pain mechanism.

Choice C reason: Cutaneous pain is skin-related, caused by direct stimuli, not abnormal nerve processing. Neuropathic pain involves nerve dysfunction, making this incorrect for the described pain type.

Choice D reason: Neuropathic pain results from abnormal pain impulse processing in the peripheral or central nervous system, such as in neuropathy or nerve injury. This matches the description, making it the correct choice.

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A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” What is the nurse’s best reply?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant’s ability to suck and grasp the mother’s finger. What is the nurse assessing?

Correct Answer is C

Explanation

The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?

Correct Answer is D

Explanation

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