Author Question: A young adult client notes height as 5 feet 11 inches and weight as 200 lbs. Upon assessment, the ... (Read 225 times)

big1devin · **on:** Jun 25, 2018

A young adult client notes height as 5 feet 11 inches and weight as 200 lbs. Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy?

1. The client does not have a scale at home.
2. The client may have an image of self that is inconsistent with actual findings.
3. The client did not want to tell the truth.
4. The client is trying to hide a chronic illness.

Question 2

The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. Which type of blood pressure reading does the nurse expect?

1. An accurate reading.
2. A falsely elevated reading.
3. The reading will depend on the overall health of the client.
4. A false low reading.

Leostella20 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2

The best reason for the inconsistency is the client has a different image of himself than what is objectively measurable. The nurse has no way of knowing if the client has a scale at home and does not account for the discrepancy in height. The inconsistency between reported height and weight and actual height and weight does not mean the client is being untruthful; it is what the client believes to be true. The inconsistency between reported height and actual height and weight does not indicate that the client is trying to hide a chronic illness.

Answer to Question 2

Correct Answer: 4

In this situation, the bladder of the cuff is too wide, resulting in the blood pressure reading being falsely low. To obtain accurate blood pressure readings, it is imperative that the nurse select the proper cuff. The bladder of the blood pressure cuff must be an appropriate fit in both length and width for the client's arm. The length of the bladder should equal 80 of the circumference of the limb. The width of the bladder should equal 40 of the circumference of the limb. In a very thin client, a small (or even pediatric) blood pressure cuff should be used to obtain an accurate reading. Using a standard cuff on this client will yield a falsely low result. When the bladder of the cuff is too narrow, the blood pressure reading will be falsely elevated. While the reading will depend on the overall health of the client, it is important to obtain an accurate reading by using the proper equipment.