The nurse is assessing a client's blood pressure to establish a ...

[lidoalex]

The nurse is assessing a client's blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data:
 
  1. Reflect a normal variation
  2. Should be reported to the client's health care provider
  3. Dictate that pressure should be monitored in the left arm
  4. Indicate that the client may be experiencing vascular problems

Question 2

The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke?
 
  1. The 75-year-old who has forgot where the car is parked
  2. The 16-year-old volunteer whose skin appears sunburned but dry
  3. The 34-year-old who finished the race and is reporting leg cramps
  4. The 55-year-old observer who complains of nausea and being thirsty

[diana chang]

Answer to Question 1

ANS: 2
During the initial assessment, obtain and record the blood pressure in both arms. Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others, 2002). In subsequent as-sessments, measure the blood pressure in the arm with the higher pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge. Reporting the assessment findings is the most appropriate outcome.

Answer to Question 2

ANS: 2
Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a body temperature sometimes as high as 45 C (113 F) with an increase in heart rate and lowering of blood pres-sure. The most important sign of heatstroke is hot, dry skin. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. If the condition progresses, the client with heatstroke becomes unconscious with fixed, unreactive pupils. Permanent neurological damage occurs unless cooling measures are rapidly started.