The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients?
1. A 25-year-old who was admitted for depression and anxiety
2. A 69-year-old diagnosed with Parkinson's disease 5 years ago
3. A 57-year-old prescribed antihypertensive medication 6 weeks ago
4. An 80-year-old client whose systolic BP is routinely assessed in the low 90s
ANS: 2
Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and the inability to cooper-ate are reasons to avoid using an electronic BP monitor. The client's Parkinson's disease causes tremors, so a manual cuff should be used when assessing this client's BP.
You might also like to view...
What is the first sign of hypovolemic shock from postpartum hemorrhage?
a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output
You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers?
A) Turn and reposition the patient a minimum of every 8 hours. B) Vigorously massage lotion into bony prominences. C) Post a turning schedule at the patient's bedside and ensure staff adherence. D) Slide, rather than lift, the patient when turning.
The parent of a 13-year-old boy is concerned because the teenager wants to hang out with friends all the time and has stated that he wants to get his ear pierced because all his friends have piercings. What is the best response from the nurse?
a. "I think you need to seek counseling for your son." b. "I think this is just a phase that will quickly pass." c. "Your son needs to find new friends." d. "Your son's behavior is normal; he is trying to assert his independence."
A patient taking ciprofloxacin (Cipro) reports pain and burning on urination. What is your best action?
a. Notify the prescriber that the patient's urinary tract infection is not responding to the drug. b. Remind the patient that the pain is related to the body eliminating the infectious bacteria. c. Instruct the patient to drink a full glass of water with each drug dose and increase fluids. d. Ask the patient whether blood or pus is also present in the urine.