The nurse notes that a client's blood pressure reading was unusually elevated. For what should the nurse assess to determine the reason for this reading?
1. Presence of pain
2. Cuff inflation was too slow
3. Blood pressure cuff too wide
4. Arm placed above the heart level
1
Rationale 1: Pain can cause the blood pressure to increase.
Rationale 2: Slow cuff inflation could cause the blood pressure to be too low.
Rationale 3: A cuff that is too wide could cause the blood pressure to be too low.
Rationale 4: Placing the arm above the level of the heart could cause the blood pressure to be too low.
Global Rationale: Pain can cause the blood pressure to increase. 2: Slow cuff inflation, a cuff that is too wide, and placing the arm above the level of the heart could cause the blood pressure to be too low.
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