What is an unexpected finding of the cardiovascular system assessment?
Blood pressure 127/65, HR 68.
Trace edema to bilateral lower ankles.
Capillary refill within 2 seconds.
Apical and radial pulses equal.
The Correct Answer is B
Choice A reason: Blood pressure 127/65 and HR 68 are within normal ranges (BP <130/<80, HR 60-100), expected in healthy cardiovascular assessments. Trace edema is abnormal, suggesting fluid retention. Assuming this is unexpected risks overlooking normal findings, diverting focus from issues like edema needing evaluation in cardiovascular assessments.
Choice B reason: Trace edema in bilateral lower ankles is an unexpected finding, indicating potential fluid overload, heart failure, or venous insufficiency. Unlike normal vitals or pulses, edema requires investigation and reporting. Recognizing this ensures timely diagnosis and management, critical for preventing progression of underlying cardiovascular or systemic conditions in affected patients.
Choice C reason: Capillary refill within 2 seconds is normal, indicating adequate peripheral perfusion, expected in cardiovascular assessments. Edema is the abnormal finding. Assuming refill is unexpected risks misprioritizing normal findings, neglecting issues like edema that signal potential heart or venous issues, critical for accurate cardiovascular evaluation and care.
Choice D reason: Equal apical and radial pulses are expected, reflecting synchronized cardiac output, normal in cardiovascular assessments. Trace edema is abnormal, suggesting fluid issues. Assuming pulses are unexpected risks overlooking normal findings, diverting attention from edema, critical for identifying and managing underlying cardiovascular conditions in clinical practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is objective, describing observable clinical findings such as facial drooping and slurred but understandable speech with appropriate word choices. It avoids speculative diagnoses, adhering to medical documentation standards that prioritize factual, measurable data. Neurological assessments often note such symptoms, which may indicate conditions like stroke or Bell’s palsy, but the statement remains descriptive, allowing for accurate clinical interpretation.
Choice B reason: Stating “the client is having a stroke” is a definitive diagnosis, which is inappropriate for a medical record without confirmatory diagnostic tests like a CT scan or MRI. Stroke involves cerebral ischemia or hemorrhage, causing symptoms like facial droop, but documentation must avoid premature conclusions to prevent misdiagnosis and ensure proper clinical evaluation.
Choice C reason: This statement is subjective, focusing on the observer’s difficulty understanding speech and using vague terms like “asymmetrical.” It lacks specificity about speech clarity or word choice, which are critical in neurological assessments. Objective documentation should quantify symptoms, such as degree of asymmetry or speech intelligibility, to support accurate medical decision-making.
Choice D reason: This statement speculates a causal link between drooping mouth and speech difficulty without evidence, using “probably,” which is inappropriate for medical records. It lacks detail on speech quality or other neurological signs. Accurate documentation requires precise, objective observations to guide diagnosis, such as noting specific symptoms without assuming unconfirmed etiologies.
Correct Answer is B
Explanation
Choice A reason: A heart rate below normal (e.g., <60 bpm) indicates bradycardia, not necessarily arrhythmia, which is characterized by irregular rhythm. Irregular heart rate defines arrhythmia. Assuming low rate risks misdiagnosis, potentially missing treatments like antiarrhythmics, critical for stabilizing rhythm and preventing complications in arrhythmic patients.
Choice B reason: Irregular heart rate is the hallmark of arrhythmia, reflecting disrupted electrical conduction (e.g., atrial fibrillation). This sign, detected via pulse or ECG, guides diagnosis and treatment like anticoagulants or cardioversion. Accurate identification ensures timely intervention, critical for preventing stroke or heart failure in patients with cardiac rhythm disturbances.
Choice C reason: Low respiratory rate is unrelated to arrhythmia, which affects heart rhythm, not breathing. Irregular heart rate is the key sign. Assuming respiratory rate misdirects focus, risking neglect of cardiac monitoring or treatment, potentially delaying management of arrhythmia and increasing risks of thromboembolism or hemodynamic instability.
Choice D reason: Decreased blood pressure upon standing (orthostatic hypotension) is unrelated to arrhythmia, which involves irregular heart rhythm. Misidentifying this risks overlooking cardiac signs like irregular pulse, delaying ECG or antiarrhythmic therapy, critical for managing arrhythmia and preventing complications like syncope or heart failure in affected patients.
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