Unit 2 - Integrative Holistic Nursing Assessment General
Status, Vital Signs, and Pain Questions With Complete
Solutions
arm bp steps? (see the videos in the lectures slides too) Correct
Answer 1. person may sit or lie down with the bare arm
supported at the heart level
2. palpate brachial artery w/ deflated bp cuff -- center it above
brachial artery (1 inch) and wrap evenly
3. palpate brachial or radial artery
4. inflate cuff until artery pulsation obliterated, then 20-30mm
hg beyond to avoid missing any auscultatory gaps
4. deflate cuff quickly and completely; wait 15-30 seconds
before reinflating so blood trapped before can leave
at what time of the day is body temp highest and lowest?
Correct Answer highest = night
lowest = right when you wake up
blood pressure mistakes to avoid? Correct Answer - wrong bp
cuff size
- do not have patient support their own arm
- if they had a mastectomy, avoid the matching arm and use the
other instead
case question: A client has an oral temperature of 37.2 (99). The
nurse interviews the client. Which of the following pieces of
data could be an influence of this temperature?
- The client just ran 3 miles outside before the interview.
- The client drinks 8 ounces of water per day.
- The client has a history of hypothyroidism.
, - The client reports a toe infection treated with antibiotics for 3
months. Correct Answer the client has a history of
hypothyroidism
case question: Mrs. Gleason is a 55 year old Caucasian female
who comes into the Emergency Center with complaints of
nausea and vomiting. She is pale and is holding her abdomen.
States her pain radiates to her back. Her boyfriend accompanies
her and says that she has been unable to eat for 2 days. Her vital
signs are T 98.6, HR 98, BP 145/65, RR 20.
- Subjective Data?
- Objective Data?
- Vitals?
- Acute vs chronic?
- Source of pain? Correct Answer Subjective Data?
- Pain radiating from back Been unable to eat for 2 days Nausea
and vomiting complaints
Objective Data?
- Pale Clutching abdomen, could mean bad posture or gait Vital
signs
Vitals?
- Temperature is normal Heart rate is normal BP is elevated
Could be because she's in pain.
Acute vs. Chronic
- This is acute pain bc it was over 2 days
Source of Pain?
- apparently this is a case of cholecystitis
case question: the nurse is caring for a patient who shows
emaciated effects and possible drug abuse. which of the
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