The nurse measures a client's blood pressure to be 158/92 mmHg. The nurse recognizes that this blood pressure is classified as:
1. normal.
2. prehypertension.
3. stage I hypertension.
4. stage II hypertension.
3
Normal blood pressure is SBP less than 120 mmHg and DBP less than 80 mmHg. A prehypertensive state is SBP of 120 to 139 mmHg or DBP of 80 to 90 mmHg. Stage I hypertension is SBP of 140 to 159 mmHg or DBP of 90 to 99 mmHg. Stage II hypertension is a SBP of 160 mmHg or higher or a DBP of 100 mmHg or higher.
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Which statement accurately differentiates NCD from pseudodementia (depression)?
1. NCD has a rapid onset, whereas pseudodementia does not. 2. NCD symptoms include disorientation to time and place, and pseudodementia does not. 3. NCD symptoms improve as the day progresses, but symptoms of pseudodementia worsen. 4. NCD causes decreased appetite, whereas pseudodementia does not.
The nurse is performing a gestational age assessment on a newborn. Which characteristic shows the greatest gestational maturity?
a. The infant's arms and legs are extended. b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum. d. The arm can be positioned with the elbow beyond the midline of the chest.
You obtain a wound culture specimen, complete the dressing change, obtain a full set of VS,note a temperature of 100.4° F (38° C), and assess increased tenderness in C.W.'s abdomen
What orders do you anticipate receiving once you notify the physician of C.W.'s condition?
When using electronic medical records (EMR), the nurse knows that the EMR:
a. holds the documentation of a single episode of care. b. is a longitudinal record of care for each patient. c. is widely used for individual health care encounters. d. includes progress notes for all disciplines.