Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

frequency

duration

location.

character

intensity

Answer and Explanation

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

A.   The frequency of pain is essential to understand how often the patient experiences pain.
B.   Duration refers to how long the pain lasts, which is an important characteristic to document.
C.   The location of pain helps determine its origin and the appropriate treatment approach.
D.   The character of the pain, such as sharp, dull, or aching, aids in identifying its nature and cause.
E.   The intensity of pain is crucial for assessing the effectiveness of pain management and guiding treatment decisions.

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Correct Answer is C

Explanation

A. Wrapping the cuff snugly around the arm is important for an accurate reading. The cuff should be snug but not tight to avoid false readings.
B. Positioning the cuff bladder over the brachial artery ensures the correct placement for accurate measurement.
C. Placing the arm above the level of the heart can lead to a falsely low blood pressure reading. The arm should be at heart level for an accurate measurement.
D. Ensuring the gauge starts at zero is critical for accurate measurement and avoids errors in reading.

A. pump up the cuff until no sound is heard and then let the air out. B. stop midway and begin to inflate again. C. make sure the bell of the stethoscope is placed firmly over the artery. D. continue to listen until the cuff is deflated.

Correct Answer is D

Explanation

Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.

C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.

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Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Correct Answer is C

Explanation

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Correct Answer is D

Explanation

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