Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

pump up the cuff until no sound is heard and then let the air out.

stop midway and begin to inflate again.

make sure the bell of the stethoscope is placed firmly over the artery.

continue to listen until the cuff is deflated.

Answer and Explanation

The Correct Answer is D

Rationale
A.   Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B.   Stopping midway can result in missing sounds or causing an inaccurate measurement.

C.   The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D.   It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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Correct Answer is A

Explanation

A. Gathering information from a family member can help obtain a more accurate history, especially when the patient has difficulty recalling specific details due to age-related memory changes.
B. Omitting the interview would lead to incomplete information and potentially delay appropriate care.
C. Repeating the questions may be helpful but may not always yield reliable data if the patient struggles to remember key details.
D. While forgetfulness can be normal with aging, healthcare providers need to ensure accurate information is collected to provide optimal care.

A. "When I shine a light into the patient's eyes, the pupils should constrict." B. "It is normal for the pupils to react sluggishly to light." C. "When I shine a light into the patient's eyes, the pupils should dilate D. "Pupil checks should be performed with the room lights on."

Correct Answer is A

Explanation

A. The normal response to light in the eye is pupil constriction. This indicates that the optic and oculomotor nerves are functioning properly.
B. While a sluggish reaction can occur in some individuals, a noticeable sluggish response could indicate neurological issues, especially in a head injury.
C. Pupils should constrict in response to light, not dilate, unless there is a significant neurological impairment.
D. Pupil checks should ideally be performed in dim lighting for better visibility of pupillary reactions, not with the room lights on.

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Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:

Correct Answer is A

Explanation

A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

Correct Answer is A

Explanation

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