A client's blood pressure readings have shown great variation since admission. Which of these actions should the nurse take next?
a. Assume the findings reflect the client's medical condition.
b. Determine whether the blood pressure cuff being used is the correct size for this client.
c. Report findings to the health care provider.
d. Review the medications ordered and the administration schedule to determine any effect on blood pressure.
B
A falsely elevated reading results if the bladder of the cuff is too narrow, and a falsely low reading results if the cuff is too wide. The cuff bladder should encircle 80% of the arm to obtain an accurate blood pressure. Obtaining two measurements ensures accuracy.
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Which of the following interventions would be appropriate when working with a woman whose nursing diagnosis is Ineffective coping related to impaired impulse control as evidenced by impulsive self-injurious behavior? (Select all that apply.)
a. Assist the patient to develop a list of effective coping options to carry for future use. b. Encourage her to use negative reinforcers (e.g., pain) to discourage undesired behavior. c. Guide the patient to examine the advantages and costs of her present coping strategies. d. Help her to practice the desired responses in role plays and later in real-life situations. e. Teach the patient to "cue" herself to stop and think before taking undesired actions. f. Consult with her psychiatrist about antianxiety medication to help reduce impulsiveness.
The nurse is interviewing a male client who states "I feel like I have a bag of worms in my scrotum.". The nurse would correctly suspect which of the following conditions?
1. Orchitis 2. Varicocele 3. Epididymitis 4. Hernia
After administration of epidural anesthesia during labor, the patient develops a temperature of 37.8°C (100.1°F). The spouse asks if the patient is "getting sick." How should the nurse respond to the patient and spouse?
A) "We will have to take her temperature every 30 minutes and might start antibiotics." B) "This elevation in temperature is a possible side effect of the anesthesia. We will notify the provider and assess temperature again in an hour." C) "Can you tell me if you have been exposed to any illnesses you might be developing?" D) "Due to the length of your labor, you might be dehydrated and that may cause your temperature to rise, let's get you something to drink."
The nurse is contributing to the plan of care for a surgical patient. What should the nurse recognize as the most common human response to the stress associated with surgery?
a. Fear b. Anxiety c. Delirium d. Depression