The nurse notes that there is a difference in a patient's blood pressure (BP) and heart rate (HR) when the patient changes position from supine to standing. The differences are a decrease of 20 mm Hg in systolic BP, a decrease of 10 mm Hg in diastolic BP, and an increase in the HR of 20 beats/minute.
Which interpretation would the nurse make about the patient's condition?
Hypertensive crisis.
An auscultatory gap.
Resistant hypertension.
Enlarged lymph nodes.
The Correct Answer is B
Choice A rationale:
Hypertensive crisis is characterized by severely elevated blood pressure, usually above 180/120 mm Hg. The given differences in blood pressure (a decrease of 20 mm Hg in systolic BP) do not indicate hypertensive crisis.
Choice B rationale:
An auscultatory gap refers to a temporary disappearance of sounds normally heard over the brachial artery during blood pressure measurement. This phenomenon can lead to inaccurate readings and might cause a delay in recognizing the true blood pressure values. In this case, the decrease in systolic BP when changing positions indicates the presence of an auscultatory gap, requiring the nurse to be vigilant during blood pressure measurements.
Choice C rationale:
Resistant hypertension is a term used when blood pressure remains above goal despite concurrent use of three antihypertensive agents of different classes. The given scenario does not indicate resistant hypertension but rather suggests a technical issue during blood pressure measurement due to the auscultatory gap.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Taking a daily walk is a beneficial activity for patients with venous leg ulcers. Walking promotes blood circulation, which can aid in wound healing. This statement indicates that the patient understands the importance of physical activity for their condition.
Choice B rationale:
Trying to lose weight is another positive step for a patient with venous leg ulcers, especially if the patient is overweight. Excess body weight can put additional pressure on the veins in the legs, worsening venous insufficiency. Losing weight can alleviate this pressure and improve venous circulation, supporting the healing process of leg ulcers.
Choice C rationale:
Wearing stockings after getting out of bed is a proper technique for managing venous leg ulcers. Compression stockings help improve blood flow in the legs and reduce swelling, which is beneficial for patients with venous insufficiency and leg ulcers. This statement indicates that the patient understands the importance of wearing compression stockings consistently.
Choice D rationale:
Not wearing knee-high socks that are tight around the calf is essential advice for patients with venous leg ulcers. Tight clothing, including socks or stockings, can impede blood circulation in the legs, worsening venous insufficiency and delaying wound healing. This statement indicates the need for further education because the patient should avoid any tight clothing around the affected area to promote optimal blood flow and wound healing.
Correct Answer is D
Explanation
Choice A rationale:
Chronic stable angina typically occurs with activity and is relieved with rest or nitroglycerin. Therefore, this statement is incorrect for chronic stable angina.
Choice B rationale:
Chronic stable angina usually lasts for a short duration, usually around 5 minutes, and is relieved with rest or nitroglycerin. Prolonged pain lasting 10-15 minutes or more could indicate an unstable angina or myocardial infarction. This choice is incorrect for chronic stable angina.
Choice C rationale:
Pain due to chronic stable angina subsides when the precipitating factor, such as physical exertion, is resolved or with medication like nitroglycerin. Therefore, this statement is incorrect for chronic stable angina.
Choice D rationale:
Chronic stable angina follows a predictable pattern, occurring intermittently over a period of time, and is usually triggered by physical exertion or emotional stress. This option correctly describes the characteristic pattern of chronic stable angina.
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