The nurse is taking the blood pressure of a client. The nurse obtains the blood pressure in both of the client's arms

Question

The nurse determines that there is a difference of 15 mm Hg in the systolic readings between the arms and repeats the assessment with the same results. The nurse suspects which of the following may have occurred in this situation? 1. Inaccurate technique
2. Anxiety
3. Unilateral arterial obstruction
4. Shock

Answer 1

3
Rationale 1: After repeating the procedure and determining the results were the same, the nurse would not necessarily assume that the technique was faulty.
Rationale 2: Client anxiety may result in a higher blood pressure reading. It would not result in a difference between blood pressures assessed in each arm.
Rationale 3: A difference of readings 10 mm Hg or more between arms may indicate an obstruction of arterial blood flow to one arm and is considered an abnormal finding.
Rationale 4: If the client is developing clinical manifestations associated with shock, the nurse would most likely determine that the client's blood pressure is lower than normal. Shock would not result in a difference between blood pressures assessed in each arm.