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 A
Explanation
A. Stress incontinence: This occurs when urine leaks due to increased abdominal pressure from activities like coughing or laughing, indicating a weakness in the pelvic floor muscles.
B. Obstructive incontinence: This is not a recognized type of urinary incontinence; it may refer to urinary obstruction issues, which are different from stress incontinence.
C. Overflow incontinence: This involves leakage due to an overfilled bladder and is not typically related to activities that increase abdominal pressure.
D. Urge incontinence: This involves a sudden, intense urge to urinate and may lead to involuntary leakage, but it is not specifically linked to coughing or laughing.
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.
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