When auscultating the blood pressure of a 25-year-old, the nurse hears the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
200/92
100/200/92
200/100
200/100/92
The Correct Answer is D
A. 200/92. This format does not include the muffling point (Phase IV), which is important in some clinical settings, such as in critically ill patients or those with vascular diseases.
B. 100/200/92. This order is incorrect because the systolic pressure should always be listed first, followed by the diastolic components.
C. 200/100. This format omits the point at which sounds completely disappear (Phase V), which is the true diastolic pressure in most cases. However, in some individuals, particularly those with conditions like aortic regurgitation, the muffling point may be recorded as an additional reading.
D. 200/100/92. The correct way to document blood pressure when Korotkoff sounds muffle before disappearing is to include all three values: the systolic pressure (Phase I), the point of muffling (Phase IV), and the diastolic pressure (Phase V). This ensures a complete and accurate blood pressure recording.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Perception. Perception occurs when the brain processes and interprets the pain signal, which happens after the stimulus has been converted and transmitted.
B. Transduction. Transduction is the process where a painful stimulus, such as touching a hot stove, causes cellular damage, leading to the release of chemical mediators that convert the stimulus into a pain impulse.
C. Modulation. Modulation involves the body's response to pain, including the release of endorphins to inhibit pain signals and reduce pain sensation.
D. Transmission. Transmission refers to the movement of the pain impulse from the site of injury to the spinal cord and brain, occurring after transduction has taken place.
Correct Answer is D
Explanation
A. Perception occurs when the brain interprets pain signals and recognizes them as pain. This step happens after the nerve impulses have been transmitted to the brain.
B. Transduction is the first step in the pain process, where painful stimuli (such as cutting a finger) activate nociceptors, converting the stimulus into an electrical signal.
C. Modulation involves the body’s response to pain signals, where descending nerve pathways release substances like endorphins to inhibit pain transmission. This occurs later in the pain process.
D. Transmission is the process of pain signals traveling from the site of injury to the spinal cord and brain via afferent nerve fibers. This step occurs after transduction and allows pain signals to reach the central nervous system.
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