A student nurse is learning to assess blood pressure. What does the blood pressure measure?

In clients who have had a stroke, especially those with facial drooping, dysphagia (difficulty swallowing), or immobility, the nurse must choose a method of taking temperature that minimizes risk (e.g., aspiration or injury) and provides consistent, accurate readings.

Rationale for correct answer:

C. Axillary: Safe, noninvasive, and easy to perform even in clients with limited mobility. While it is less accurate than core sites, it’s a reasonable alternative when oral and rectal sites are contraindicated.

D. Tympanic: Quick, noninvasive, and reflects core temperature well. Not affected by oral or facial dysfunctions. Can be performed even when the client has limited cooperation.

E. Temporal artery: Noninvasive, fast, and generally well tolerated. Can be used in immobile or neurologically impaired clients without requiring cooperation.

Rationale for incorrect answers:

A. Oral: Oral temperature measurement requires the client to close their mouth tightly around the probe, which is compromised by facial drooping and dysphagia.

B. Rectal: While rectal temperature is accurate, it is invasive and can be uncomfortable, particularly in older or immobile clients.

Take-home points:

• Avoid oral and rectal routes in clients with neurologic deficits, swallowing issues, or limited mobility due to safety concerns.
• Axillary, tympanic, and temporal artery methods are safe, noninvasive, and appropriate for clients with stroke-related impairments.

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.