The unlicensed assistive personnel (UAP) brings the nurse the ...

[olgavictoria]

The unlicensed assistive personnel (UAP) brings the nurse the following vital signs for an older adult client:
 
  Temperature 97.4 F (oral), BP 165/70, pulse rate 84/min., and respirations 28. After reviewing the vital signs, which action by the nurse is the most appropriate?
  1. Continue to monitor the client.
  2. Tell the UAP to recheck the temperature.
  3. Obtain an order for an antihypertensive.
  4. Obtain an order for oxygen therapy.

Question 2

The nurse is obtaining the height and weight of an older adult client. The client asks why the height is 1 inch less than last year. Which response by the nurse is the most appropriate?
 
  1. Your bones are weaker and are shrinking.
  2. I am sure you are mistaken and just don't remember from last year.
  3. Your height decreases with age due to musculoskeletal changes.
  4. Stand up straighter this time and we will measure again.

[Dnite]

Answer to Question 1

Correct Answer: 1

Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against, which can result in an increased systolic blood pressure. No interventions are needed at this time. The temperature is within a normal range for this client; there is no need to recheck the temperature. While the systolic blood pressure reading is higher than the upper limit of normal, one elevated reading of 165 systolic is not an indication for antihypertensive therapy. The nurse should continue to monitor this client's blood pressure and alert the healthcare provider if the systolic blood pressure remains elevated. The client's vital signs are within a normal range; there is no indication for oxygen therapy.

Answer to Question 2

Correct Answer: 3
Height of older adults may decrease as a result of thinning of the intervertebral discs. There can also be a flexion of the hips and knees, which affects the ability to stand erect. During the older adult years the bones may lose density, but they do not shrink. To confront the client and say I am sure you are mistaken and just don't remember from last year is an inappropriate response and does not answer the client's question.

[olgavictoria]

Thank you

[Dnite]

No problemo