Author Question: A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over ... (Read 62 times)

frankwu · **on:** Jul 22, 2018

A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff.

The nurse should recognize the client's peak blood pressure when what sound is audible? A) A whooshing sound that quickly intensifies
B) A clicking sound that appears suddenly
C) The lub dub of the client's heart rate
D) A faint, clear tapping sound

Question 2

A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. The nurse recognizes that this client has what condition?

A) Fecal impaction
B) Iatrogenic constipation
C) Fecal incontinence
D) Secondary constipation

jordangronback · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
Feedback:
Korotkoff sounds have five unique phases. Phase I begins with the first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff. When the first sound occurs, it corresponds to the peak pressure in the arterial system during heart contraction, or the systolic pressure measurement. This sound does not have the two-stage sound of a heartbeat.

Answer to Question 2

A
Feedback:
The client has fecal impaction because the large, hardened mass of stool is interfering with defecation. Iatrogenic constipation occurs as a consequence of other medical treatment. Secondary constipation is a consequence of a pathologic disorder. Fecal incontinence is the inability to control the elimination of stool.