After taking the vital signs of a client, the nurse notes the client has a high systolic blood pressure reading. Which factors should the nurse include when explaining the possible cause of this increase? Select all that apply.

Caffeine intake

Post meal

Stress

Drinking a glass of water

Time of day

Answer and Explanation

Correct Answer : A,C,E

A. Caffeine intake: Can cause a temporary increase in blood pressure due to its stimulant effects.

B. Post meal: While eating can cause temporary changes in blood pressure, it is less likely to be a significant factor compared to other causes.

C. Stress: Can lead to temporary increases in blood pressure due to the body's stress response.

D. Drinking a glass of water: Typically does not significantly affect blood pressure unless there is an underlying issue such as dehydration.

E. Time of day: Blood pressure can naturally vary throughout the day, often being higher in the morning and lower in the evening.

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Correct Answer is D

Explanation

A. Percuss, inspect, auscultate, palpate: This sequence is incorrect because inspection should be performed first to assess the abdomen visually.

B. Auscultate, inspect, palpate, percuss: This sequence is incorrect because auscultation should follow inspection and before palpation and percussion.

C. Palpate, percuss, inspect, auscultate: This sequence is incorrect as palpation and percussion should not come before inspection.

D. Inspect, auscultate, percuss, palpate: This is the correct sequence. Inspection is first, followed by auscultation to listen to bowel sounds, then percussion to assess for fluid or gas, and finally palpation to check for tenderness or masses.

A. Increased jugular venous pressure B. Decreased right-sided volume C. Decreased stroke volume D. Decreased central venous pressure

Correct Answer is A

Explanation

A. Increased jugular venous pressure: Right-sided heart failure often leads to increased jugular venous pressure due to the backup of blood in the systemic venous system.

B. Decreased right-sided volume: Right-sided heart failure typically results in increased blood volume in the right heart chambers, not decreased.

C. Decreased stroke volume: While right-sided heart failure can affect stroke volume, increased jugular venous pressure is a more direct indicator of right-sided heart failure.

D. Decreased central venous pressure: Right-sided heart failure usually results in increased, not decreased, central venous pressure.

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After taking the vital signs of a client, the nurse notes the client has a high systolic blood pressure reading. Which factors should the nurse include when explaining the possible cause of this increase? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Correct Answer is D

Explanation

On examination, the nurse would expect what finding if a client is in right-sided heart failure?

Correct Answer is A

Explanation

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