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Pulse pressure is defined as the numerical difference between the systolic blood pressure (the higher value) and the diastolic blood pressure (the lower value). It is represented by a numeric value in millimeters of mercury (mmHg). For example, if the systolic pressure is 120 mmHg and the diastolic pressure is 80 mmHg, the pulse pressure would be 40 mmHg (120 - 80 = 40).

Explanation:

The rubber bladder inside the cuff should have a width that is approximately 40% to 50% of the arm circumference. This allows for proper inflation and accurate measurement of blood pressure.

The other options are incorrect because

• The length of the cuff should equal 80%, not 100%, of the arm circumference
• The standard cuff size is not appropriate for all individuals, as it can lead to inaccurate readings
• The width of the rubber bladder should equal 40%, not 80%, of the arm length

A functional assessment is a process of evaluating a person’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as bathing, dressing, eating, shopping, and managing medications. A functional assessment can help identify the level of care and support a person needs to maintain their quality of life and independence.

Based on this definition, the appropriate question by the nurse when performing a functional assessment on a client diagnosed with COPD is:

• Are you able to bathe yourself?

This question directly assesses the client’s ability to perform an ADL that may be affected by their respiratory condition.

The other options are not relevant to a functional assessment because:

Do you wear dentures? This question does not assess an ADL or an IADL, but rather a personal preference or condition that may or may not affect the client’s function.

When was your last bowel movement? This question does not assess an ADL or an IADL, but rather a physiological function that may be related to other factors besides COPD.

Do you have any problems swallowing? This question does not assess an ADL or an IADL, but rather a symptom that may be associated with other conditions besides COPD.

Inspection involves visually examining the client's body and specific areas for any signs of abnormalities, changes, or visible cues related to their health. It provides valuable initial

information about the client's overall appearance, skin color, posture, symmetry, and any visible abnormalities or distress.

After performing inspection, the nurse would typically proceed with the other assessment techniques in the following order:

1. Inspection: Visual examination of the client's body and specific areas.
2. Palpation: Using touch to assess texture, temperature, moisture, tenderness, and the presence of masses or abnormalities.
3. Percussion: Tapping or striking body parts to produce sounds that indicate the density of underlying structures.
4. Auscultation: Listening to sounds produced by the body using a stethoscope, such as heart sounds, lung sounds, or bowel sounds.

Are you still employed at the same job? This question is not open-ended, but rather yes or no, as it only requires a simple answer from the client. This question is also not relevant to the purpose of the interview, which is to assess the client’s health, not their employment status. This question may also be insensitive or intrusive, as it may imply that the client’s job is a source of stress or dissatisfaction.

A tool is a device or instrument that helps to perform a task or achieve a goal. Cultural competence is the ability to effectively interact with people belonging to different cultures. Therefore, a tool for building cultural competence in nursing should help nurses to develop and apply this skill in their practice.

Based on this definition, the best tool for building cultural competence in nursing is:

• The cultural assessment competency tool

This tool is a framework or a guide that helps nurses to conduct a comprehensive and systematic cultural assessment of their clients. A cultural assessment involves collecting and analyzing information about the client’s cultural beliefs, values, practices, and preferences related to health and illness. This information can help nurses to provide culturally appropriate and respectful care that meets the client’s needs and expectations.

ou are doing very well with these questions. A database is a collection of information that is organized and accessible for analysis and decision making. In nursing, a database includes the client’s health history, physical examination findings, laboratory and diagnostic test results, and

other relevant data. The type and amount of data collected depend on the purpose and scope of the assessment.

Based on this definition, the best answer to what the nurse will include in the client’s database is:

Data linked with lifesaving measures

A complete health history: This answer is not correct because a complete health history is a comprehensive and detailed account of the client’s past and present health status, including biographical data, family history, personal and psychosocial history, review of systems, and health patterns. It is usually done during the initial contact with a client or during a wellness visit. It is not feasible or necessary for a client with an acute problem in the Emergency Department.

This is the correct technique. Gentle pressure should be used to palpate the lymph nodes with both hands, allowing for comparison between the two sides. This method helps the nurse accurately assess the size, consistency, mobility, and tenderness of the lymph nodes.

Pain is a subjective and multidimensional experience that involves sensory, emotional, cognitive, and behavioral components. Pain assessment is the process of gathering information from the client about their pain and its impact on their function and quality of life.

Based on this definition, the best question by the nurse to assess the intensity of a client’s pain is:

• How much pain do you have now?

A review of systems (ROS) is a systematic method of collecting subjective data from the client about their health status and any symptoms they may have related to each body system. A ROS is part of a comprehensive health history, which also includes biographical data, chief complaint, history of present illness, past medical history, family history, personal and psychosocial history, and health patterns.

Based on this definition, the purpose of the review of systems in a health history is to:

Evaluate the past and present health state of each body system

This answer is correct because a ROS helps to identify any current or previous health problems or concerns that the client may have in relation to each body system. A ROS also helps to screen for any risk factors or potential complications that may affect the client’s health.