Nursing Elites

1. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

• A. These readings are a normal response and attributable to changes in the patient's position.
• B. The change in blood pressure readings is called orthostatic hypotension.
• C. The blood pressure reading in the lying position is within normal limits.
• D. The change in blood pressure readings is considered within normal limits for the patient's age.

Correct answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of ³20 mm Hg or ³10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.

2. A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. What rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?

• A. Controls stray electrical currents.
• B. Promotes efficient use of electricity.
• C. Shuts off the appliance if there is an electrical surge.
• D. Divides the electricity among the appliances in the room.

Correct answer: A

Rationale: A three-pronged plug functions as a ground to dissipate stray electrical currents. This helps prevent electrical shocks and ensures the safety of the user. Choice B is incorrect because the number of prongs on a plug does not impact the efficient use of electricity. Choice C is incorrect because a three-pronged plug does not shut off the appliance during an electrical surge; that role is typically fulfilled by surge protectors. Choice D is incorrect as a three-pronged plug does not divide electricity among appliances in a room; it primarily serves as a safety measure to handle excess electrical currents.

3. The mitral valve is synonymous with the term:

• A. Left ventricle
• B. Right atrium
• C. Bicuspid valve
• D. Tricuspid valve

Correct answer: C

Rationale: The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle, regulating blood flow from the left atrium into the left ventricle. The term 'bicuspid' refers to the valve's two cusps or leaflets. This distinguishes it from the tricuspid valve (Choice D), which has three cusps, making Choice D incorrect. The left ventricle (Choice A) and right atrium (Choice B) are not synonymous with the mitral valve. Therefore, the correct answer is C: Bicuspid valve.

4. Which acronym would BEST describe the procedure for assessing a patient that appears unconscious?

• A. WBC
• B. QRS
• C. XYZ
• D. ABC

Correct answer: D

Rationale: The correct answer is D, 'ABC.' The ABC method stands for Airway, Breathing, Circulation. When encountering an unconscious patient, it is crucial to first ensure their Airway is clear by performing the 'head tilt, chin lift' maneuver. Next, assess Breathing by observing for chest rise and fall, listening for breath sounds, and feeling for airflow. Finally, check for Circulation by assessing for a pulse. Choices A, B, and C ('WBC,' 'QRS,' 'XYZ') are incorrect as they do not represent the standard approach to assessing an unconscious patient.

5. What message is a patient sending when displaying the following body language: Slumped shoulders, grimace, and stiff joints?

• A. Anger
• B. Aloofness
• C. Empathy
• D. Depression

Correct answer: A

Rationale: Body language is a powerful form of non-verbal communication that can convey various emotions. In this scenario, the patient's slumped shoulders, grimace, and stiff joints suggest a negative emotional state. Anger is the correct answer because grimacing and tense posture are commonly associated with anger. Choice B, 'Aloofness,' is incorrect as aloofness is more related to disinterest or detachment, which is not indicated by the described body language. Choice C, 'Empathy,' is incorrect as the body language described does not align with expressing understanding or compassion towards others. Choice D, 'Depression,' is incorrect as while depression can also manifest through body language, the specific cues given in the scenario lean more towards anger than depression.

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