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: The epidermis is the most superficial skin layer, providing a protective barrier against pathogens and UV radiation. Composed of stratified squamous epithelium, it’s critical for skin integrity. Accurate identification guides wound care and assessments, ensuring proper management of superficial injuries or conditions like dermatitis in clinical practice.
Choice B reason: Adipose tissue is deep, within the subcutaneous layer, not superficial. The epidermis is the outermost layer. Misidentifying adipose risks misunderstanding skin anatomy, leading to errors in wound staging or treatment, potentially compromising care for superficial skin conditions requiring targeted interventions like topical therapies.
Choice C reason: The subcutaneous layer lies beneath the dermis, not superficially. The epidermis is the outermost layer. Assuming subcutaneous is superficial misguides skin assessments, risking incorrect wound care or misdiagnosis of skin conditions, critical for accurate treatment and prevention of complications in integumentary health.
Choice D reason: The dermis lies below the epidermis, containing blood vessels and nerves, not the most superficial layer. Misidentifying dermis risks errors in assessing skin injuries or conditions, potentially leading to inappropriate treatments. Recognizing the epidermis ensures proper care for superficial issues like burns or abrasions in clinical settings.
Correct Answer is C
Explanation
Choice A reason: Pain level assessment is important but unrelated to orientation, which evaluates mental state via time, place, and person questions. Assuming pain assesses orientation risks missing cognitive deficits, delaying diagnosis of delirium or dementia, critical for tailoring care and interventions in patients with altered mental status.
Choice B reason: Personal hygiene reflects self-care ability, not orientation to time, place, or person, which assesses mental state. Assuming hygiene evaluates orientation misguides assessment, risking oversight of cognitive impairments, essential for diagnosing conditions like Alzheimer’s or acute confusion, requiring targeted interventions in clinical practice.
Choice C reason: Orientation questions assess mental state, evaluating cognitive function through awareness of time, place, and person. This detects impairments in conditions like delirium or dementia, guiding care planning. Accurate assessment ensures timely interventions, critical for managing cognitive decline and supporting patient safety and communication in healthcare settings.
Choice D reason: Family medical history provides genetic context but doesn’t assess orientation, which targets mental state. Assuming history evaluates orientation risks missing cognitive issues, delaying diagnosis of acute or chronic cognitive impairments, critical for implementing cognitive support or pharmacological interventions in patients with suspected mental status changes.
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