Various sounds are heard when assessing a blood pressure. What does the second sound heard through the stethoscope represent?

Systolic pressure

Pulse pressure

Auscultatory gap

Diastolic pressure

Answer and Explanation

The Correct Answer is D

A. Systolic pressure:

The first sound heard during blood pressure measurement corresponds to the systolic pressure, the pressure in the arteries when the heart is contracting.

B. Pulse pressure:

Pulse pressure is the numerical difference between the systolic and diastolic pressures but is not specifically represented by a sound in blood pressure measurement.

C. Auscultatory gap:

An auscultatory gap is a temporary disappearance of sounds during blood pressure measurement, typically occurring between the systolic and diastolic pressures. It is not directly associated with the second sound.

D. Diastolic pressure:

The second sound heard corresponds to the closure of the aortic valve, marking the beginning of diastole. This sound represents the diastolic pressure, which is the pressure in the arteries when the heart is at rest.

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Correct Answer is C

Explanation

A. Comatose:

A comatose state is characterized by an unarousable and unresponsive condition. Individuals in a coma do not respond to external stimuli, including shaking or calling their name.

B. Stuporous:

Stupor is a state of near-unconsciousness or insensibility. A stuporous patient may require more intense stimulation to achieve a response than someone who is lethargic.

C. Lethargic:

Lethargy is a state of drowsiness or fatigue. Lethargic patients may appear drowsy but can be awakened by gentle stimulation, such as shaking and calling their name.

D. Awake and Alert:

An awake and alert state implies full responsiveness, awareness, and orientation to the environment. The patient in the scenario does not fit this description.

A. Make sure the bed is low, locked, and call light in reach of patient B. Ask the client if they have ordered their dinner C. Educate the client on the surgical procedure they are scheduled for in the morning D. Check that the client is wearing non-skid socks while in bed

Correct Answer is A

Explanation

A. Make sure the bed is low, locked, and the call light is in reach of the patient:

This action is crucial for preventing falls. A low bed reduces the risk of injury if the client were to accidentally fall. Locking the bed prevents unintended movement, and ensuring the call light is within reach allows the client to call for assistance if needed.

B. Ask the client if they have ordered their dinner:

While nutrition is important, it is not the immediate priority after assisting the client back to bed. Safety measures should be addressed first.

C. Educate the client on the surgical procedure they are scheduled for in the morning:

While pre-operative education is important, it is not the immediate concern after assisting the client back to bed. Safety measures for the current situation take precedence.

D. Check that the client is wearing non-skid socks while in bed:

While wearing non-skid socks is a safety measure, ensuring the bed is low, locked, and the call light is accessible is a more immediate and critical action after assisting the client back to bed.

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Various sounds are heard when assessing a blood pressure. What does the second sound heard through the stethoscope represent?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

Correct Answer is A

Explanation

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