ahQ2 Flashcards
A client’s weight has increased by 4 lb over the past 72 hours. What should the nursing assistant interpret the weight gain to most likely indicate?
Fluid accumulation
A client’s weight can fluctuate as his or her fluid balance changes. Significant, short-term changes in weight are unlikely to be the result of nutritional factors.
Which type of thermometer is the most accurate is least invasive?
temporal artery thermometer
A young client arrives on the unit and the nursing assistant obtains a blood pressure of 68/48 mm Hg. Which disorder will the nursing assistant predict this client has?
Hypotension
Accepted normal ranges for the ________ pressure are between 90 and 120 mm Hg and for the _________ pressure, between 60 & 80 mm Hg for an adult.
Systolic, Diastolic
Pulse Rhythm
pattern of the pulsations & the pauses between each pulsation
The number of pulsations felt in 1 minute is the _____ ____.
Pulse Rate
The force or quality of the pulse refers to the _____ ____________.
Pulse Amplitude
The nurse has asked the nursing assistant to assess a client’s apical heart rate before administering medication. Which is the best position for the nursing assistant to place the client to obtain an accurate measurement?
Before listening to a client’s or resident’s apical pulse, the person should be helped into a semi-sitting position by raising the head of the bed. The other positions would not be appropriate to obtain an accurate apical pulse.
The nurse has stated to the nursing assistant and documented a client’s pulse as “weak and thready.” Which aspect of the pulse is the nurse referring to?
The term pulse amplitude refers to the force or quality of the heart rate and the ease or difficulty of palpating it. The pulse rate is how many pulsations can be felt in 1 minute. The pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse value could indicate how many beats per minute the heart contracts giving the pulse rate.
The nurse notes an 83-year-old female resident appears flushed and requests the nursing assistant check vital signs. Which conclusion would best explain an oral temperature of 99.8°F?
Older adults may have a less pronounced fever response than younger people. As such, even a mild fever (such as 99.8°F) should be followed up appropriately. The normal high oral temperature is 99.6°F, making this being slightly abnormal and elevated. This would not be an indication of the heart circulation. That would be better determined by the pulse or blood pressure.
The nurse reports to the nursing assistant the client has orthostatic hypotension. Which situation should the nursing assistant be prepared for when caring for this client?
Sudden decrease in blood pressure that occurs when a person stands up from a sitting or lying position
Dyspnea
labored or difficult respirations
Febrile
elevated body temperature
The nursing assistant has been asked by the nurse to check a client’s blood pressure. Which is the best position for the nursing assistant to place the client’s arm for this task?
When taking a blood pressure, the person’s arm should be positioned level with the heart with the palm facing up. The other positions will not give the most accurate reading.
The nursing assistant has responded to a call light in a client’s room and finds the client lying on the floor. Her roommate states that the client fell immediately after standing up from the edge of the bed. Which health problem is most likely occurring in this client?
Orthostatic Hypotension
