Question

SITUATION: A different types of patient with abnormalities in their vital signs.

1. Which method should the nurse use to obtain the blood pressure of a client with both a known auscultatory gap and a peripheral circulation problem?

1. Auscultatory method in the non- dominant arm.
2. Auscultatory method in the thigh.
3. Palpatory method in either arm.
4. Flush method in either arm.

2. A client has a temperature of 101°F (37.7°C) and is shivering and complaining that he is cold. Which of the symptoms would help to confirm that the fever is in the onset stage?

1. Pale, cold skin.
2. Flushed, warm.
3. Increased thirst.
4. Sweating.

3. Many agencies use electronic tympanic membrane thermometers. Which of the following is true regarding their use?

1. Repeated measurements are very consistent.
2. Results are obtained very quickly.
3. Readings are more accurate than rectal temperature.
4. It is a completely safe procedure.

4. The nurse is unable to palpate the client’s popliteal pulse. Presence f which of the following pulses indicates adequate popliteal artery flow?

1. Femoral.
2. Pedal.
3. Brachial.
4. Carotid.

5. The nurse assessed the pulse rate of a 44- year- old female to be 110 and not regular. Which of the following terms could be used to describe the client’s pulse?

1. Bradycardic and normal sinus rhythm.
2. Tachycradic and decreased pulse volume.
3. Bradycardic and dysrhytmic.
4. Tachycradic and dysrythmic.

SITUATION: A bedridden client is admitted to the hospital with a wound that itches and is draining a secretion irritating to the surrounding skin. During your initial assessment, you see that the skin around the wound is red, swollen, and broken.

1. Which of the following would be the most appropriate nursing diagnosis?

1. Impaired skin integrity related to wound drainage.
2. Impaired skin integrity related to immobility.
3. Risk for impaired skin integrity related to pruritus
4. Risk for impaired skin integrity related to redness.

2. Which of the following clients is at greatest risk for developing a pressure ulcer?

1. A 50- year- old man hospitalized for spinal surgery.
2. A 60- year- old man in a nursing home for three months, but who can still ambulate with help.
3. An 80 – year- old woman hospitalized for head injury.
4. An 80 – year- old woman who cannot turn herself in bed.

3. A client has an ischemic wound. This means that there has been:

1. A deficient blood supply to the tissue.
2. Damage to the small blood vessels.
3. Compression of the tissue.
4. A combination of friction and pressure.

4. The nurse understands that a client with edema is predisposed to pressure ulcers because of:

1. Decreased body utilization of vitamin.
2. Maceration of the skin.
3. Increased distance between the capillaries and the cells.
4. Increased amount of padding between the skin and the bones.

5. The elderly are at high risk for impaired skin integrity because they have:

1. Generalized thickening of the epidermis.
2. Increased vascularity in the dermis.
3. Decreased elasticity due to changes in the collagen fibers of the dermis.
4. Increased skin turgor due to changes in the sebaceous glands.

Answer 1

Situation 1.

1) d

Flush method in either arm is preferred for BP measurement in patients with known auscultatory gap (making auscultatory method inaccurate) and peripheral circulatory problems (making conventional palpatory method inaccurate)

2) a

Fever in onset stage patients have pale, cold skin. Whereas in late stages patients experience sweating with flushed, warm skin.

3) b

Numerous reasons have been suggested for the widespread introduction of the tympanic thermometer, but probably the most significant is the speed with which temperature readings can be achieved. To obtain an accurate recording a mercury thermometer bulb has to be in contact with the patient for 6-11 minutes, while tympanic thermometers take only a few seconds to obtain a reading. This aids a more rapid diagnosis, which is particularly important in areas such as A&E and critical care.

4) b

Presence of of pedal pulses indicate adequate popliteal artery flow as the pedal arteries are anatomically distal to the popliteal artery and any occlusion in the political artery would result in diminishing of pedal pulses.

5) d

Pulse rate of more than 100 - tachycardia

Pulse of irregular rhythm - dysrhythmic