The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question is most important for the nurse to ask?

"Do you eat three meals per day?"

"Who eats meals with you?"

"Do you snack in the evening?"

"How do you prepare your food?"

Answer and Explanation

The Correct Answer is D

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Correct Answer is C

Explanation

A. Palpable: This describes whether the pulse can be physically felt, which is useful for assessing circulation but does not answer the physician’s request. Pulse pressure is a numerical value, not a descriptive term, and cannot be reported as "palpable."
B. Within normal limits: This is a nonspecific and subjective response. It does not provide the precise data the physician requested. Accurate clinical communication requires the nurse to report the actual pulse pressure value to aid in diagnosis and treatment decisions.
C. 24: Pulse pressure is calculated by subtracting diastolic from systolic pressure (102 − 78 = 24 mm Hg). This value is low and may indicate decreased cardiac output, early shock, or heart failure. It is the correct and medically appropriate response to the physician’s question.
D. Thready: This term refers to the strength or amplitude of the pulse, often noted during palpation. Although it suggests poor perfusion, it does not provide a quantitative measurement. It’s unrelated to the actual calculation of pulse pressure, which is what the physician needs.

A. Increased cardiac output B. Decreased pulmonary pressure C. Decreased right ventricular pressure D. Increased left atrial pressure

Correct Answer is D

Explanation

A. Increased cardiac output: Mitral stenosis typically reduces cardiac output due to impaired left ventricular filling. Increased output would be unusual but not immediately concerning compared to pressure-related complications.
B. Decreased pulmonary pressure: Pulmonary pressure often increases, not decreases, in mitral stenosis due to blood backing up from the left atrium. Decreased pressure is not a critical concern in this condition.
C. Decreased right ventricular pressure: This is not commonly associated with mitral stenosis. The right ventricle may experience increased pressure if pulmonary hypertension develops, but a decrease is less concerning.
D. Increased left atrial pressure: Mitral valve narrowing impairs blood flow into the left ventricle, leading to blood accumulation and elevated pressure in the left atrium. This can cause pulmonary congestion and is the most critical finding.

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The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question is most important for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is caring for a client with mitral stenosis. Which assessment finding would cause the greatest concern in providing nursing care to this client?

Correct Answer is D

Explanation

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