which of the following is a true statement about assessing blood pressure by palpation

NCLEX-RN

Health Promotion and Maintenance NCLEX RN Questions

1. Which of the following is a true statement about assessing blood pressure by palpation?

A. Only the diastolic blood pressure can be assessed through palpation.
B. The palpation technique is most useful for infants and small children.
C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
D. Only the systolic blood pressure can be assessed through palpation.

Correct answer: D

Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.

2. In which of the following examples would informed consent not be required?

A. A patient is apprehensive about an upcoming surgery and chooses not to learn of the risks involved with the procedure.
B. A child is rushed to the Emergency Room after falling from a third-story window.
C. An adult in a coma in a mental health institution with no listed next of kin.
D. Informed consent is not required in any of the above examples.

Correct answer: D

Rationale: In emergency situations where immediate treatment is necessary to prevent further harm or save a life, such as in option B where a child is rushed to the Emergency Room after a fall, informed consent may be waived to provide prompt care. In option A, though the patient is apprehensive about surgery and chooses not to learn the risks, informed consent is not required as it is the patient's right to refuse information. In option C, when an adult is in a coma with no next of kin listed, decisions may be made in the patient's best interest following legal and ethical guidelines. Therefore, informed consent is not needed in any of the scenarios presented.

3. Which example best describes the concept of beneficence?

A. A nurse provides pain medication for a client in the recovery room who is experiencing pain
B. A client has an advanced directive in place stating that he does not want intubation if he needs CPR
C. At the request of the client, a nurse does not inform the family about his cancer diagnosis
D. A nurse withholds narcotic medication for a client in pain, knowing that he is currently disoriented

Correct answer: A

Rationale: Beneficence is the ethical principle of doing good and acting in the best interest of the client. Providing pain relief to a client in the recovery room who is experiencing pain aligns with beneficence as it promotes the client's well-being and comfort. Choice B is related to autonomy, where the client's wishes regarding treatment are respected. Choice C involves confidentiality and the client's right to privacy. Choice D represents nonmaleficence, as withholding pain medication from a client in pain could cause harm and goes against the principle of doing no harm.

4. Which example best describes a nurse who exhibits moral courage?

A. A nurse feels angry when a parent refuses important treatment for his child.
B. A nurse considers seeking help for depression when she feels she cannot meet the needs of her clients in the oncology unit.
C. A nurse contacts a physician for further orders when he fails to order comfort measures for a client with a terminal illness.
D. A nurse is frustrated when the laboratory is slow in responding to an order for a stat blood glucose.

Correct answer: C

Rationale: Moral courage involves taking action to do what is right, even when there might be negative consequences. The nurse who contacted a physician for further orders acted as a client advocate to seek help, even though she may have faced consequences such as lost time, decreased productivity, or criticism from the physician. Choices A, B, and D do not directly involve advocating for a client's needs or challenging a situation that goes against ethical standards. Feeling angry, seeking help for personal issues, or being frustrated with work processes do not necessarily demonstrate moral courage in the context of nursing practice.

5. What preparation is necessary for a colposcopy procedure?

A. NPO for 8-12 hours before the procedure.
B. D/C all hypertension medications for two days prior to the procedure.
C. Take three Dulcolax tablets and two containers of Miralax the day before to clear out the lower GI system.
D. None of the above prep is necessary for this type of procedure.

Correct answer: D

Rationale: A colposcopy procedure is performed to examine the vagina and cervix. The only preparation required is washing the external genitals with soap and water on the morning of the procedure. Choices A, B, and C suggest unnecessary preparations that are not relevant to a colposcopy. NPO for 8-12 hours, discontinuing hypertension medications, and using laxatives are not part of the standard preparation for a colposcopy.