Procedures and Care - NCLEX-PN
Card 0 of 1644
A 39-year-old man presents to the ER with weakness, confusion, and vertigo. His heart rate is 91 and bounding, blood pressure is 
, temperature is 
, and blood glucose is 
. He is non-diabetic, he is not on any medication, and he denies recreational drug use. Which of the following is the most likely cause of his symptoms?
A 39-year-old man presents to the ER with weakness, confusion, and vertigo. His heart rate is 91 and bounding, blood pressure is
The most likely cause of his symptoms is hypoglycemia, which is defined as a blood glucose below 
in a non-diabetic patient. The symptoms of hypoglycemia include altered consciousness, tremors, weakness, vertigo, headaches, heart palpitations, and a bounding pulse.
A temperature of 
is not considered abnormal as it may reflect a normal variation in body temperature.
His blood pressure is slightly elevated, but it is unclear whether this is typical for him or whether this represents a significant change from his normal blood pressure. Regardless it would not likely be sufficiently elevated to cause his symptoms.
It is also possible he may be experiencing a panic attack, but in the presence of his depressed blood sugar (and absence of signs of anxiety), hypoglycemia is the most likely cause of his symptoms.
The most likely cause of his symptoms is hypoglycemia, which is defined as a blood glucose below
A temperature of
His blood pressure is slightly elevated, but it is unclear whether this is typical for him or whether this represents a significant change from his normal blood pressure. Regardless it would not likely be sufficiently elevated to cause his symptoms.
It is also possible he may be experiencing a panic attack, but in the presence of his depressed blood sugar (and absence of signs of anxiety), hypoglycemia is the most likely cause of his symptoms.
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Abdominal rigidity and decreased bowel sounds would raise your suspicions of what condition?
Abdominal rigidity and decreased bowel sounds would raise your suspicions of what condition?
Abdominal rigidity and decreased bowel sounds are classic signs of peritontis. In addition, the patient will often want to lie very still, as any motion often increases pain. Cystitis, ulcerative colitis, and cholecystitis all may cause significant abdominal tenderness but would not generally result in rigidity or decreased bowel sounds.
Abdominal rigidity and decreased bowel sounds are classic signs of peritontis. In addition, the patient will often want to lie very still, as any motion often increases pain. Cystitis, ulcerative colitis, and cholecystitis all may cause significant abdominal tenderness but would not generally result in rigidity or decreased bowel sounds.
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Why are blind finger-sweeps not recommended in infants with foreign objects in their oral cavities or airways?
Why are blind finger-sweeps not recommended in infants with foreign objects in their oral cavities or airways?
Blind finger sweeps are not recommended in an infant with airway restriction due to a foreign object because they may inadvertently force the object deeper into the airway. A finger sweep should only be used if the object can be visualized. Injury to the oral cavity would not be a primary concern in the case of airway restriction, and a finger sweep would not be expected to trigger either gasping or vomiting in an infant.
Blind finger sweeps are not recommended in an infant with airway restriction due to a foreign object because they may inadvertently force the object deeper into the airway. A finger sweep should only be used if the object can be visualized. Injury to the oral cavity would not be a primary concern in the case of airway restriction, and a finger sweep would not be expected to trigger either gasping or vomiting in an infant.
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All of the following are forms of shock except .
All of the following are forms of shock except .
The four main categories of shock are as follows:
- Cardiogenic: Sudden inability of the heart to pump sufficient blood to the body, most commonly due to acute myocardial infarction.
- Hypovolemic: Due to loss of fluids or hemorrhage.
- Septic: Also known as endotoxic shock. Dangerously low blood pressure as the result of systemic inflammatory response to infection.
- Anaphylactic: Systemic inflammatory response to an allergen.
The four main categories of shock are as follows:
- Cardiogenic: Sudden inability of the heart to pump sufficient blood to the body, most commonly due to acute myocardial infarction.
- Hypovolemic: Due to loss of fluids or hemorrhage.
- Septic: Also known as endotoxic shock. Dangerously low blood pressure as the result of systemic inflammatory response to infection.
- Anaphylactic: Systemic inflammatory response to an allergen.
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Identify the disorder that presents the following signs and symptoms: numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause.
Identify the disorder that presents the following signs and symptoms: numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause.
Conversion disorder is typified by numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause. Schizophrenia, bipolar disorder, and stiff person syndrome all have medically identifiable causes.
Conversion disorder is typified by numbness, paralysis, loss of vision, or other neurological symptoms after a traumatic or stressful event, without any identifiable medical cause. Schizophrenia, bipolar disorder, and stiff person syndrome all have medically identifiable causes.
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What is the best approach towards dealing with a delirious patient?
What is the best approach towards dealing with a delirious patient?
Delirium is an organic dysfunction of the brain usually seen in sick patients post-op. These patients need frequent reorientation to name, time, and place until the delirium resolves. Agitation, confusion, and difficult to control behavior is typically controlled with antipsychotics, however, they are not first line treatment. Restraints should be avoided at all costs.
Delirium is an organic dysfunction of the brain usually seen in sick patients post-op. These patients need frequent reorientation to name, time, and place until the delirium resolves. Agitation, confusion, and difficult to control behavior is typically controlled with antipsychotics, however, they are not first line treatment. Restraints should be avoided at all costs.
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How might an overlarge cuff affect a blood pressure reading?
How might an overlarge cuff affect a blood pressure reading?
An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.
An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.
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A stethoscope has two components to the chest piece. These are called the and the .
A stethoscope has two components to the chest piece. These are called the and the .
The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.
The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.
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While assessing a patient's blood pressure, what part of the stethoscope should be placed against the patient's antecubital fossa: the bell, or the diaphragm?
While assessing a patient's blood pressure, what part of the stethoscope should be placed against the patient's antecubital fossa: the bell, or the diaphragm?
When taking a patient's blood pressure, the diaphragm alone should be used to listen at the antecubital fossa. The bell, used for low-pitched sounds, would not give the examiner accurate enough information to assess systolic or diastolic pressure.
When taking a patient's blood pressure, the diaphragm alone should be used to listen at the antecubital fossa. The bell, used for low-pitched sounds, would not give the examiner accurate enough information to assess systolic or diastolic pressure.
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Which of the following would be considered a normal adult blood pressure?
Which of the following would be considered a normal adult blood pressure?
Normal adult blood pressure is anywhere from 90-120 mmHg systolic over 60-80 mmHg diastolic. 120-140 mmHg over 80-90 mmHg would be considered pre-hypertension, while anything over that would be considered either stage I or stage II hypertension.
Normal adult blood pressure is anywhere from 90-120 mmHg systolic over 60-80 mmHg diastolic. 120-140 mmHg over 80-90 mmHg would be considered pre-hypertension, while anything over that would be considered either stage I or stage II hypertension.
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A nurse takes a patient's blood pressure and records it at 146/92 mmHg. This is the patient's first visit to the clinic and they have no past medical records available. Would this patient be diagnosed with hypertension?
A nurse takes a patient's blood pressure and records it at 146/92 mmHg. This is the patient's first visit to the clinic and they have no past medical records available. Would this patient be diagnosed with hypertension?
A patient with a one-time high blood pressure reading can not be diagnosed as hypertensive. A diagnosis of hypertension requires at least three measurements of blood pressure over 140/90 mmHg on at least two separate visits to health care provider.
A patient with a one-time high blood pressure reading can not be diagnosed as hypertensive. A diagnosis of hypertension requires at least three measurements of blood pressure over 140/90 mmHg on at least two separate visits to health care provider.
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A patient with a blood pressure reading of 168/102 mmHg on three or more occasions would be diagnosed with what stage of hypertension?
A patient with a blood pressure reading of 168/102 mmHg on three or more occasions would be diagnosed with what stage of hypertension?
Stage II hypertension is defined as a blood pressure equal to or greater than 160 mmHg systolic over 100 mmHg diastolic, taken at three different times on at least two separate occasions. Stage I hypertension is systolic blood pressure of 140-160 mmHg or diastolic blood pressure of 90-100 mmHg, while prehypertension is defined as a systolic blood pressure of 120-140 mmHg or diastolic blood pressure of 80-90 mmHg.
Stage II hypertension is defined as a blood pressure equal to or greater than 160 mmHg systolic over 100 mmHg diastolic, taken at three different times on at least two separate occasions. Stage I hypertension is systolic blood pressure of 140-160 mmHg or diastolic blood pressure of 90-100 mmHg, while prehypertension is defined as a systolic blood pressure of 120-140 mmHg or diastolic blood pressure of 80-90 mmHg.
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Which of the following is not a normal part of taking a patient's vitals?
Which of the following is not a normal part of taking a patient's vitals?
While most examiners remember to take the pulse, temperature, and blood pressure while assessing their patient's vitals, overall visual appearance is also an important part of an individuals vitals. Does the patient appear ill? Anxious? Are there any noticeable issues with hygiene or bizarre dress or movements? Are there any signs of pallor, jaundice, or cyanosis? All of these observations can be quickly noted in a patient's chart when taking vitals.
While most examiners remember to take the pulse, temperature, and blood pressure while assessing their patient's vitals, overall visual appearance is also an important part of an individuals vitals. Does the patient appear ill? Anxious? Are there any noticeable issues with hygiene or bizarre dress or movements? Are there any signs of pallor, jaundice, or cyanosis? All of these observations can be quickly noted in a patient's chart when taking vitals.
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The pulse of your patient is 120 beats per minute. What is the appropriate term for this finding?
The pulse of your patient is 120 beats per minute. What is the appropriate term for this finding?
Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.
Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.
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The physician on call pages you to ask if the patient you are taking care of is afebrile. Which of the following vital signs would you find in an afebrile patient?
The physician on call pages you to ask if the patient you are taking care of is afebrile. Which of the following vital signs would you find in an afebrile patient?
Afebrile is a term used to describe a patient who does not have a fever. Clinically, a fever is defined as a temperature greater than 100.4 Fahrenheit. Blood pressure, heart rate, and respiratory rate do not tell you if the patient has a fever.
Afebrile is a term used to describe a patient who does not have a fever. Clinically, a fever is defined as a temperature greater than 100.4 Fahrenheit. Blood pressure, heart rate, and respiratory rate do not tell you if the patient has a fever.
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A 2+ radial pulse is considered to be .
A 2+ radial pulse is considered to be .
The following scale applies to the amplitude of a pulse when palpated at the radial artery:
3+ is an increased or bounding pulse
2+ is a normal pulse
1+ is a weak pulse
0 is an absent pulse
The following scale applies to the amplitude of a pulse when palpated at the radial artery:
3+ is an increased or bounding pulse
2+ is a normal pulse
1+ is a weak pulse
0 is an absent pulse
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Which of the following locations is most appropriate for assessing the pulse of an infant?
Which of the following locations is most appropriate for assessing the pulse of an infant?
The most appropriate location for assessing the pulse of an infant is the brachial artery, which travels from the axilla down the ventral surface of the upper arm to the cubital fossa. The popliteal and radial pulses are difficult to palpate on an infant due to their size, and the carotid artery can be difficult to palpate due to an infant's shorter, thicker neck.
The most appropriate location for assessing the pulse of an infant is the brachial artery, which travels from the axilla down the ventral surface of the upper arm to the cubital fossa. The popliteal and radial pulses are difficult to palpate on an infant due to their size, and the carotid artery can be difficult to palpate due to an infant's shorter, thicker neck.
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Which of the following is a normal adult respiratory rate?
Which of the following is a normal adult respiratory rate?
Normal adult respiratory rate is 12-20 breaths per minute. A respiratory rate below 12 is defined as bradypnea, while a respiratory rate above 20 is considered tachypnea.
Normal adult respiratory rate is 12-20 breaths per minute. A respiratory rate below 12 is defined as bradypnea, while a respiratory rate above 20 is considered tachypnea.
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What is a normal respiratory rate for an infant under 1 year of age?
What is a normal respiratory rate for an infant under 1 year of age?
Infants have the highest respiratory rate of any age group. A normal infant respiratory rate is 30-60 breaths per minute.
Infants have the highest respiratory rate of any age group. A normal infant respiratory rate is 30-60 breaths per minute.
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What is a normal respiratory rate for a child aged 1-6 years old?
What is a normal respiratory rate for a child aged 1-6 years old?
A normal respiratory rate in a child aged 1-6 years is 24-34 breaths per minute. This is significantly higher than an adult normal respiratory rate, which is 12-20 breaths per minute.
A normal respiratory rate in a child aged 1-6 years is 24-34 breaths per minute. This is significantly higher than an adult normal respiratory rate, which is 12-20 breaths per minute.
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