A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?

Apply the largest cuff available.

Use the palpatory method to determine blood pressure.

Place the arm above the level of the client’s heart.

Deflate the cuff quickly.

Answer and Explanation

The Correct Answer is B

This method involves feeling the radial pulse while inflating and deflating the cuff.

The systolic pressure is estimated by noting the pressure at which the pulse disappears and reappears. The diastolic pressure is not measured by this method, but it can be useful when the sounds are difficult to hear.

Choice A is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.

Choice C is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.

Choice D is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly.

Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.

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Correct Answer is C

Explanation

This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.

The other choices are incorrect for the following reasons:

Choice A is not a typical sign of coarctation of the aorta.

Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.

Choice B is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.

Choice D is not directly related to coarctation of the aorta.

Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.

Normal ranges for blood pressure and pulse vary depending on age, sex, and health status. However, some general guidelines are:

Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.

A. Implement firm but flexible boundaries in their relationship. B. Minimize open discussion regarding the changes to avoid embarrassment. C. Encourage authoritative communication from the adult child. D. Decrease socialization with extended relatives until roles are identified.

Correct Answer is A

Explanation

This is because boundaries can help the client and family to respect each other’s roles, needs, and preferences, and to avoid role confusion, resentment, or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration, or isolation. The client and family should communicate openly and honestly about their feelings, expectations, and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.

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A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

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A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?