A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

The site where the blood pressure was obtained.

Interventions implemented in response to a client's blood pressure.

A client's position when the blood pressure was obtained.

The frequency in which a blood pressure is taken.

A client's response to interventions implemented.

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B.   Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C.   A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or

standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D.   The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E.   A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.

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Correct Answer is A

Explanation

A: Due to age-related reductions in gastrointestinal muscle efficiency, which slows the digestive process and can lead to increased water absorption from stool.
B: Overstates the issue, not all elderly patients experience difficulties, and it does not account for individual variability or other influencing factors like diet and medication.
C: Misrepresents the frequency and reasons for laxative use among the elderly, not all of whom misuse these medications.
D: While changes in rectal sphincter elasticity can affect some elderly individuals, it is less commonly a direct cause of constipation compared to decreased peristalsis.

A. Check the blood pressure with the client in a supine position. B. Place the client in a sitting position. C. Determine the client's blood pressure 1 min after each position change. D. Assist the client into a standing position.

Correct Answer is A

Explanation

A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.

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