During a routine vital sign assessment, you note the client's blood pressure is 212/110. Why is this finding particularly significant?
A) It allows the nurse to have a baseline value
B) It deviates from normal and is significant
C) It is due to the fact the client is fearful
D) It is related to a tumor of the adrenal
Ans: B
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Which of the following factors of a health-care system foster effective family-focused communication?
1. An environment that uses complex technology. 2. A nurse's stance that health-care providers maintain power in a relationship. 3. Educational materials that consider the health literacy of families. 4. A family's fears and anxiety about an individual member's illness.
A patient is very short of breath. Which finding should cause the nurse to be concerned that the shortness of breath might be due to heart failure?
1. An echocardiogram that reflected increased right ventricular wall thickening 2. A B-type natriuretic peptide (BNP) of 300 pg/mL 3. A left ventricular ejection fraction (VEF) of 50% 4. A serum sodium of 135
C.J. is a 48-year-old concert pianist. Before her performance this evening, she told a friend that she was
experiencing what she called "the worst headache I've ever had" and that she had taken two extra strength acetaminophen (Tylenol ES), but they "didn't touch my headache." During her performance, she stopped playing, reached up, grasped her head, and then fell unconscious. When the paramedics arrived, she was intubated and an intravenous (IV) line was started with normal saline.