The client has morbid obesity and the nurse uses a blood pressure cuff that is too narrow for the client's arm. Which does the nurse encounter because of the blood pressure cuff?
1. Cannot hear the Korotkoff sounds
2. Obtains palpable blood pressure only
3. Has difficulty positioning a stethoscope
4. Obtains false high blood pressure results
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4. Using a cuff that is too narrow results in a false high blood pressure measurement and makes care planning impossible. The nurse owes a duty to the client to obtain a properly sized blood pressure cuff as soon as possible; the nurse continues to measure the blood pressure with the improper cuff and provides close observation to ensure client safety and prevent injury until the correct cuff arrives.
1. Hypovolemia, irregular or ventricular arrhythmias, and obesity potentially lead to diminished Korotkoff sounds; the assessment finding warrants further investigation by the nurse.
2. A palpable blood pressure provides a systolic pressure only and the nurse obtains a palpable blood pressure by inflating the cuff to occlude the artery and then palpating the brachial or radial pulse. The point at which the pulse returns is the systolic pres-sure. The palpable pressure is likely to result in a false high reading because the cuff is too narrow.
3. The nurse should have less difficulty positioning the stethoscope because the nar-row cuff exposes more skin.
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a. Content analysis b. Statistical analysis c. Coding of themes d. Dissemination
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While providing care to a client with a mental disorder, the client asks the nurse, "Does mental illness run in your family?" Which response by the nurse would be most inappropriate?
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