A client has arrived at the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?
Position the arm so that it is below waist level.
Palpate the radial artery to confirm a pulse is present.
Ask the client to sit quietly in a chair for 5 minutes.
Make sure the arm selected is covered with clothing.
The Correct Answer is C
Choice A Reason:
Positioning the arm below waist level is not recommended when measuring blood pressure. It can result in an inaccurate reading, typically showing a higher blood pressure due to the effects of gravity on the blood column. The arm should be positioned at heart level for an accurate measurement.
Choice B Reason:
While palpating the radial artery to confirm a pulse is present is part of the overall assessment of circulation, it is not a necessary step immediately before measuring blood pressure. The focus should be on ensuring the client is in the correct position and is relaxed to avoid any factors that might artificially alter the blood pressure reading.
Choice C Reason:
Asking the client to sit quietly in a chair for 5 minutes is the correct procedure before measuring blood pressure. This allows the client's heart rate and blood pressure to stabilize, providing a more accurate measurement. Any activity or stress can temporarily raise blood pressure, so this quiet time is crucial.
Choice D Reason:
The arm selected for blood pressure measurement should not be covered with clothing. Clothing can constrict the blood pressure cuff and interfere with the accuracy of the reading. The cuff should be placed on bare skin to ensure it inflates and deflates correctly and that the stethoscope can accurately detect the sounds of the blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice a reason:
A BMI of 27 falls into the 'Overweight' category according to the standard BMI classification. The 'Overweight' range is defined as a BMI of 25 to 29.9. This indicates that the person's weight is higher than what is considered healthy for a given height.
Choice b reason:
'Obesity Class I' is characterized by a BMI of 30 to 34.9. Since the client's BMI is 27, it does not reach the threshold for this category.
Choice c reason:
The 'Normal weight' category ranges from a BMI of 18.5 to 24.9. With a BMI of 27, the client exceeds the upper limit of the normal weight range.
Choice d reason:
The term 'Obesity' generally refers to a BMI of 30 or higher, which encompasses Obesity Class I, II, and III. Since the client's BMI is 27, it is below the obesity range.
Correct Answer is C
Explanation
Choice A Reason:
While falls are a common cause of injury in children, they are not the leading cause of TBI in adolescents. Falls tend to be more frequent in the younger population, particularly in children under the age of 4. In adolescents, sports-related injuries and motor vehicle accidents are more prevalent causes of TBI.
Choice B Reason:
The statement that females have twice the risk of TBI compared to males is incorrect. National data reveal that males are at increased risk of TBI compared to females, especially in the adolescent age group. This is likely due to higher engagement in risk-taking behaviors and contact sports.
Choice C Reason:
Concussions in sports and motor vehicle accidents are indeed the leading causes of TBI in adolescents. Engaging in contact sports such as football, hockey, and soccer can lead to concussions, which are a form of mild TBI. Motor vehicle accidents are also a significant risk factor due to high-impact collisions that can cause head injuries.
Choice D Reason:
Firearm incidents are a serious concern for TBI; however, they are not the most common cause of TBI in adolescents. While firearm-related injuries can be severe and are a leading cause of TBI-related deaths, concussions from sports and motor vehicle accidents account for a larger number of non-fatal TBIs in this age group.
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