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 B

Explanation

A. Bronchitis primarily causes coughing and mucus production, and does not specifically relate to trouble breathing while lying down.

B. Heart failure often leads to orthopnea (difficulty breathing while lying flat) and paroxysmal nocturnal dyspnea (waking up at night with difficulty breathing). These symptoms align with the client's reported issues.

C. Pneumonia usually presents with acute symptoms such as cough, fever, and chest pain, rather than the specific nocturnal breathing difficulty described.

D. Tuberculosis typically involves symptoms like chronic cough, night sweats, and weight loss, rather than difficulty breathing while lying down.

A. Flat murmur B. Diastolic murmur C. Absent murmur D. Systolic murmur

Correct Answer is D

Explanation

A. A flat murmur does not accurately describe the type of murmur associated with mitral insufficiency.

B. Mitral insufficiency is typically classified as a systolic murmur, not diastolic.

C. An absent murmur would indicate no audible sound, which is not applicable here.

D. Mitral insufficiency or regurgitation is characterized by a systolic murmur due to the backflow of blood from the left ventricle into the left atrium during systole.

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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

During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following?

Correct Answer is B

Explanation

A mitral insufficiency/regurgitation murmur is classified as:

Correct Answer is D

Explanation

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