After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?

Continue with the blood pressure assessment.

Reposition the stethoscope over the brachial artery.

Reinflate the cuff to a higher number.

Note the presence of an auscultatory gap.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.

Choice B rationale:

Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

Choice C rationale:

Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.

Choice D rationale:

Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

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Correct Answer is B

Explanation

Choice A rationale:

The statement, "This medication will help regulate my mood and anxiety," is an accurate description of how antidepressants work. Antidepressants can help improve mood and reduce anxiety symptoms over time.

Choice B rationale:

This is the correct answer. Expecting immediate results from antidepressant medication is a misunderstanding. Antidepressants typically take several weeks to show their full therapeutic effects. Clients need to be informed about the delayed onset of action.

Choice C rationale:

The statement, "I may experience side effects such as nausea and drowsiness," is accurate. Antidepressants can indeed cause side effects, including gastrointestinal symptoms like nausea and drowsiness. This information is essential for the client to be aware of.

Choice D rationale:

This statement is correct. It is crucial to take antidepressant medication consistently as prescribed for the best therapeutic outcomes. Stopping or missing doses without consulting a healthcare provider can lead to treatment ineffectiveness.

A. Ketonuria. B. Peripheral edema. C. Hypokalemia. D. Elevated blood pressure.

Correct Answer is C

Explanation

Choice A rationale:

Ketonuria is not a common complication of diabetes insipidus. Ketonuria is associated with diabetes mellitus, a different condition that results in the accumulation of ketones in the urine due to insufficient insulin.

Choice B rationale:

Peripheral edema is also an unlikely complication of diabetes insipidus. Diabetes insipidus is characterized by excessive thirst and urination, not fluid retention or peripheral edema.

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After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

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After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?