The blood pressure measurement for a client is very different from the one that was assessed a few hours previously. The nurse should suspect that the blood pressure measurement is false when which of the following is assessed in the client?
1. Client needs to void.
2. Client smoked a cigarette 10 minutes prior to the measurement.
3. The examination room is very warm.
4. Doors are slamming and children are crying in the environment.
5. Client just had lunch.
6. Client slept for 8 hours the previous night.
1, 2, 3, 4
Factors that cause false blood pressure readings include anxiety, full urinary bladder, excessively warm room, recent tobacco use, and loud or repetitive noises. Eating a meal or having 8 hours of sleep are not known to cause a false blood pressure reading.
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ANS:
For which older patient should the nurse suspect a decline in the responsiveness of the immune system?
1. 78-year-old patient with pneumonia and temperature of 99.5°F 2. 68-year-old patient with a red itchy rash from contact with poison ivy 3. 80-year-old patient with swelling and redness around an abdominal incision 4. 66-year-old patient with 8 mm induration from a mumps skin test 72 hours earlier
What are supportive interventions that can assist an adolescent with a chronic illness to meet developmental milestones? (Select all that apply.)
a. Encourage activities appropriate for age. b. Avoid discussing planning for the future. c. Provide instruction on interpersonal and coping skills. d. Emphasize good appearance and wearing of stylish clothes. e. Understand that the adolescent will not have the same sexual needs.
The nurse evaluates that wearing bifocals improved the patient's myopia and presbyopia by assessing for
a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.