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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Aortic murmurs: These are best assessed with the client in an upright or slightly leaning forward position, not specifically the left lateral position.
B. Atrial repolarization: This is not directly assessed by body position; it is part of the ECG assessment.
C. The first heart sound: The first heart sound (S1) is heard throughout the auscultation process and is not specifically enhanced by a left lateral position.
D. Mitral stenosis: The left lateral position allows better auscultation of the mitral area, where mitral stenosis murmurs are best heard.
Correct Answer is A
Explanation
A. Posterior tibial: The posterior tibial pulse is palpated just behind the medial malleolus of the ankle, near the Achilles tendon.
B. Femoral: The femoral pulse is located in the groin area, where the femoral artery passes.
C. Popliteal: The popliteal pulse is palpated behind the knee in the popliteal fossa.
D. Dorsalis pedis: The dorsalis pedis pulse is located on the top of the foot, near the first metatarsal.
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