A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?
Systolic blood pressure
Location of blood pressure cuff
Unit of measurement
Position of the client
The Correct Answer is B
A. The systolic blood pressure is clearly stated as "102 mm Hg" in the documentation. There is no need for clarification regarding the systolic value.
B. It is essential to document the site where the blood pressure was taken, as this can affect the accuracy of the reading. Typically, the blood pressure is measured in the brachial artery in the upper arm. If the cuff was placed on a different site, such as the wrist or ankle, this should be noted in the documentation.
C. The unit of measurement for blood pressure is correctly indicated as "mm Hg" (millimeters of mercury). There is no need for clarification regarding the unit since it is standard and clear.
D. The position of the client is correctly documented as sitting up in a chair.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Varicella, or chickenpox, is transmitted via airborne transmission. The varicella virus can spread through respiratory droplets and can also linger in the air after an infected person has left the area. Thus, it is included in airborne transmission.
B. Clostridium difficile (C. diff) is primarily transmitted through contact, particularly via contaminated surfaces and the fecal-oral route. It is not considered an airborne disease. Therefore, this option is incorrect.
C. Tuberculosis (TB) is a classic example of a disease transmitted via airborne transmission. TB bacteria are spread through the air when an infected person coughs, sneezes, or talks, allowing the bacteria to remain suspended in the air and be inhaled by others. This option is correct.
D. Rubeola, or measles, is also transmitted via airborne transmission. The measles virus can be spread through respiratory droplets, and the virus can remain airborne for up to two hours after an infected person has left the area. This option is correct.
E. Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA), is primarily transmitted through direct contact with contaminated surfaces or skin, as well as through contact with infected wounds. It is not typically spread through airborne transmission.
Correct Answer is B
Explanation
A. This is not a therapeutic communication technique. Passive responses can create barriers to communication and may lead to misunderstandings. They often convey a lack of interest or engagement, which is counterproductive in therapeutic settings.
B. This is a valuable therapeutic communication technique. Silence allows clients to reflect on their thoughts and feelings, giving them the space to express themselves without pressure. It can encourage deeper conversation and provide opportunities for the nurse to observe non-verbal cues.
C. Offering personal opinions is generally not considered a therapeutic communication technique. It can shift the focus away from the client and may inadvertently lead to judgment or bias. Instead,
therapeutic communication emphasizes listening and understanding the client’s perspective without imposing personal views.
D. While offering sympathy may seem caring, it can sometimes lead to a focus on the nurse's feelings rather than the client's experience. Sympathy may not promote empowerment or exploration of the client’s feelings as effectively as empathy, which involves understanding and validating the client's
emotions without imposing one’s own feelings.
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