A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

The site where the blood pressure was obtained.

Interventions implemented in response to a client's blood pressure.

A client's position when the blood pressure was obtained.

The frequency in which a blood pressure is taken.

A client's response to interventions implemented.

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B.   Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C.   A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or

standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D.   The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E.   A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.

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Correct Answer is D

Explanation

A: Low blood pressure is an objective finding that can be measured directly.

B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.

D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.

A. It is common for intestinal peristalsis to slow down as a person ages, causing problems with constipation. B. Aging patients always have difficulty having a bowel movement while hospitalized C. Elderly patients almost always abuse laxatives, which creates problems with constipation. D. In elderly patients, the rectal sphincter has lost elasticity, which decreases the sensation of urgency.

Correct Answer is A

Explanation

A: Due to age-related reductions in gastrointestinal muscle efficiency, which slows the digestive process and can lead to increased water absorption from stool.
B: Overstates the issue, not all elderly patients experience difficulties, and it does not account for individual variability or other influencing factors like diet and medication.
C: Misrepresents the frequency and reasons for laxative use among the elderly, not all of whom misuse these medications.
D: While changes in rectal sphincter elasticity can affect some elderly individuals, it is less commonly a direct cause of constipation compared to decreased peristalsis.

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A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

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