A nurse is assessing a client who has the following vital signs: oral temperature 37.2° C (98.9° F), apical pulse rate 80/min, radial pulse rate 62/min, respiratory rate 16/min, and blood pressure 132/40 mm Hg. What is the client's pulse pressure?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.

B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.

C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.

D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.

A. Insisting on direct eye contact may be uncomfortable or distressing for some clients, particularly those with certain mental health conditions or cultural backgrounds. It's important to respect the client's comfort level.

B. Seating the client too far away can create a sense of distance and may hinder effective communication. A closer seating arrangement facilitates rapport and engagement.

C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially if they have concerns about their safety or autonomy.

D. Leaning in slightly when speaking to the client demonstrates attentiveness and engagement. It can also convey a sense of confidentiality and respect for the client's space.