A client is admitted with a head injury and may develop neurogenic fever. Which nursing diagnosis would be most appropriate for this client?

Blood pressure (BP) measurement is a foundational clinical assessment, but its accuracy is highly influenced by technique, cuff size, body position, and external factors.

Rationale for correct answers:

A. Cuff too small on the device: A cuff that is too small for the client’s arm can result in falsely elevated systolic pressure.

D. Patient did not remove his long-sleeved shirt: Taking BP over clothing can interfere with cuff compression and cause falsely high readings, especially thicker or tight sleeves.

E. Insufficient time between measurements: Taking repeat BP readings too soon (e.g., within 1–2 minutes) doesn’t allow time for vascular recovery and can lead to falsely high results.

Rationale for incorrect answers:

B. Arm positioned above heart level: If the arm is above heart level, BP readings tend to be falsely low, not high. To avoid error, the arm should be at heart level.

C. Slow inflation of the cuff by the machine: Slow deflation, not inflation, affects BP accuracy.

Take-home points:

• Improper cuff size, measuring over clothing, and not waiting long enough between readings can all cause falsely elevated BP.
• BP measurement should be performed with the arm at heart level, cuff directly on skin, and with the correct-sized cuff to ensure accuracy.

Pneumonia typically causes fever, tachypnea, increased heart rate, and reduced oxygen saturation. Treatment goals include reducing fever and infection, improving oxygenation, and relieving respiratory distress.

Rationale for correct answers:

A. Temperature: 37°C (98.6°F): This indicates that the fever has resolved, showing the antibiotics may be working and inflammation is decreasing.

B. Radial pulse: 98: The heart rate decreased from 112 to 98 bpm, reflecting reduced sympathetic response (less fever, improved oxygenation).

C. Respiratory rate: 18: A drop from 22 to 18 breaths/min indicates eased breathing, improved oxygen exchange, and reduced respiratory distress.

D. Oxygen saturation: 96%: An increase from 94% to 96% on 2 L oxygen suggests better gas exchange and alveolar function.

Rationale for incorrect answers:

E. Blood pressure: 134/78: Clinically stable but not the best indicator of pneumonia recovery. BP has remained within the normal range and is slightly lower than baseline (138/82).

Take-home points:

• Positive treatment outcomes in pneumonia include lowered fever, normalized respiratory rate, improved oxygen saturation, and decreasing heart rate.
• While blood pressure stability is important, it is less specific for tracking pneumonia recovery compared to respiratory and oxygenation parameters.