During a cardiovascular assessment, the nurse notes that the patient has a jugular vein distension (JVD) when positioned at 45 degrees. What does this finding suggest?

Correct Answer: C

Rationale: The correct answer is C: Right-sided heart failure. Jugular vein distension (JVD) at 45 degrees indicates increased central venous pressure, commonly seen in right-sided heart failure. In this condition, the weakened right heart is unable to pump effectively, leading to venous congestion and JVD. Dehydration (B) typically presents with decreased jugular venous pressure. Pulmonary embolism (D) may cause JVD, but it's usually accompanied by other symptoms. JVD is not a normal finding (A) at 45 degrees and suggests an underlying pathology.

Correct Answer: B

Rationale: Higher than, is correct because core body temperature (e.g., rectal, tympanic) is typically 0.5°F-1°F higher than surface temperature (e.g., oral, axillary) due to proximity to internal organs and less environmental influence. Core sites reflect true metabolic heat, averaging 98.6°F-100.4°F, while surface sites like skin average 97°F-99°F. Less than, reverses this fact. Equal to, ignores the gradient. None of the above, dismisses the clear difference. This distinction is vital in nursinge.g., rectal readings are higher and more stable than axillary, guiding fever assessment. Physiological principles and clinical tools (e.g., thermometers) confirm B as the correct answer.

Correct Answer: B

Rationale: IV fluids in the right arm interfere with accurate blood pressure measurement due to altered circulation and pressure. Taking it in the left arm avoids this, ensuring a reliable reading. Using the right arm risks inaccuracy. A small cuff doesnt address the IV issue and may overestimate pressure. Reporting inability is unnecessary when the left arm is viable. Choice B is correct, reflecting standard practice to use the unaffected limb.

Correct Answer: B

Rationale: Tepid sponge baths and cool compresses lower temperature via conduction , transferring heat from the skin to the cooler objects through direct contact. Radiation involves heat loss to the environment without contact, not the primary method here. Convection requires air movement (e.g., fans), not used. Evaporation occurs with moisture vaporizing, a minor effect with tepid water but not dominant. Choice B is correct as conduction is the main mechanism, aligning with nursing interventions to reduce fever by physically drawing heat away from the body.

Correct Answer: D

Rationale: In assessing a 3-year-old's blood pressure, the correct approach is to explain the procedure to the child (Option D). This is important for several reasons. First, explaining the procedure helps build trust with the child, reducing anxiety and fear associated with the assessment. This can lead to a more accurate reading as the child is more likely to cooperate. Second, involving the child in the process promotes their understanding of healthcare practices from a young age, fostering a positive attitude towards medical care in the future. Option A is incorrect because using the diaphragm portion of the stethoscope to detect Korotkoff sounds is more appropriate for adults, not children. Option B is incorrect as it is essential to allow the child to settle down to obtain an accurate reading, as a child's blood pressure can be influenced by their activity level and emotions. Option C is incorrect because the cuff size should be based on the child's arm circumference, not simply on the label 'Child' or 'Infant.' Educationally, teaching healthcare providers the importance of child-friendly communication and involving children in their care can improve patient outcomes and experiences. It is crucial to adapt assessment techniques to the developmental stage of the child to ensure accurate readings and provide a positive healthcare experience.