When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Wrapping the cuff too loosely around the client's arm

Measuring blood pressure right after the client's mealtime

Positioning the client's arm above heart level

Deflating the cuff too slowly

Answer and Explanation

The Correct Answer is C

The correct answer is: c. Positioning the client’s arm above heart level.

Choice A: Wrapping the cuff too loosely around the client’s arm

Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.

Choice B: Measuring blood pressure right after the client’s mealtime

Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.

Choice C: Positioning the client’s arm above heart level

Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.

Choice D: Deflating the cuff too slowly

Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.

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Correct Answer is B

Explanation

Choice A reason: Going to bed and waking up at the same times each day is a recommended practice for good sleep hygiene. It helps to regulate the body's internal clock and can improve sleep quality.

Choice B reason: Watching television until falling asleep is not recommended for healthful sleep habits. The light emitted from screens can interfere with the body's production of melatonin, the hormone that regulates sleep, and can make it more difficult to fall asleep.

Choice C reason: Avoiding naps, especially in the afternoon or evening, can help ensure that a person is sufficiently tired at bedtime, which can improve the ability to fall asleep and maintain sleep throughout the night.

Choice D reason: Having a small snack and taking a bath before bed can be part of a relaxing bedtime routine. A light snack can prevent hunger from disrupting sleep, and a warm bath can help to relax the body and signal that it's time to wind down.

A. Restlessness B. Clenching C. Grimacing D. Drowsiness E. Groaning

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Restlessness can be a sign of discomfort or pain, especially in a postoperative client. It may manifest as constant shifting or an inability to remain still, indicating that the client is trying to find a position that alleviates the pain.

Choice B reason: Clenching, such as tightly gripping the handrails of the bed or making fists, can indicate that the client is trying to manage pain or discomfort through tension in the muscles.

Choice C reason: Grimacing, or making a pained facial expression, is a clear nonverbal cue of pain. It often involves furrowing the brow, closing the eyes tightly, or contorting the mouth.

Choice D reason: Drowsiness is not typically a direct indicator of pain. It may be related to medication effects, fatigue, or the body's response to healing post-surgery. However, it does not specifically signal pain.

Choice E reason: Moaning, groaning, or making other vocal sounds can be a response to pain, particularly in clients who are unable to articulate their pain verbally due to sedation or other factors.

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When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Choice A: Wrapping the cuff too loosely around the client’s arm

Choice B: Measuring blood pressure right after the client’s mealtime

Choice C: Positioning the client’s arm above heart level

Choice D: Deflating the cuff too slowly

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

Correct Answer is B

Explanation

A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

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