An older adult patient experienced a fall during the previous night shift, and the care team suspects that the patient may be experiencing orthostatic hypotension.
When assessing this patient for postural changes in blood pressure (BP), the nurse should:
A) Record the patient's standing, sitting and lying BPs in prompt succession while assisting the patient in transitions
B) Ask the patient to begin by adopting the position that most often causes him or her to feel dizzy then assess BP in a variety of positions
C) Take BP readings when the patient is lying, sitting, and standing with a minimum period of 30 minutes between each measurement
D) Assess the patient's BP in supine, feet dangling, and then standing positions with 1 to 3 minutes of waiting between each reading.
Question 2The earliest sign of increased intracranial pressure is
a. headache.
b. dilated pupil.
c. decreasing level of consciousness.
d. diplopia (double vision).
Question 3The nurse is conducting a head-to-toe assessment of a patient at the beginning of a shift. The nurse has palpated the patient's radial pulse for 1 minute to determine the patient's heart rate and has detected an irregular rhythm.
How should the nurse follow-up this assessment finding?
A) Continue to palpate the patient's radial pulse for one more minute in order to gauge the severity of the arrhythmia.
B) Palpate the patient's right and left radial pulses simultaneously to compare the symmetry of the patient's rate and rhythm.
C) Reposition the patient, wait 3 to 5 minutes and then reassess the patient's radial pulse.
D) Auscultate the patient's apical pulse while simultaneously palpating the patient's radial pulse.
Question 4An elderly woman suffering from abdominal pain, nausea, urinary incontinence, fever, and vomiting is brought to the emergency department. What is the most likely preliminary diagnosis?
A) Appendicitis
B) Aneurysm
C) Urinary tract infection
D) Colon cancer
Question 5In assessing a patient with suspected Bell's palsy, what clinical manifestations might be present?
a. Inability to wrinkle forehead and pucker lips
b. Inability to touch nose with finger with eyes closed
c. Symmetric facial expressions
d. Excruciating lightninglike shock in lips
Question 6Following the morning assessment of an older adult patient, the nurse has documented, Edema 3+ present to ankles and feet; dorsalis pedis and posterior tibial pulses palpable bilaterally.
The nurse should recognize that this patient may be exhibiting symptoms of:
A) Heart failure
B) Angina pectoris
C) Intermittent claudication
D) Hypertension
Question 7Albert, Bob, Charlie, and David wandered into a health food store when they were mall-walking one morning. They decided to try various remedies that might boost their resistance to infection.
According to claims made about the following remedies, which man is most likely to increase his immunity? A) Albert, who substituted soy for dairy foods.
B) Bob, who began taking vitamins C and A everyday.
C) Charlie, who began eating large quantities of onions.
D) David, who increased his intake of sugar and began taking Siberian ginseng.
Question 8The best nursing intervention for restlessness in a patient with a head injury is
a. sedation with an available narcotic.
b. restraints to prevent injury.
c. assessing for pain or distended bladder.
d. encouraging verbalization of the problem.
Question 9A 76-year-old resident of an assisted living facility who has a history of heart failure has presented to her primary care provider for a scheduled appointment. Which of the woman's statements suggests that her heart failure is worsening?
A) The last few weeks I've found that I'm more comfortable sleeping in a chair than in my bed.
B) I find that I have to wake up two or three times a night to go to the washroom, which never used to be the case.
C) I find that my appetite is not what it used to be, and I have to will myself to eat enough healthy food.
D) I pride myself in staying alert and up-to-date but lately I've forgotten a few important events.
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