A 56-year-old male client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response?
"Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination."
"We will need to reevaluate your blood pressure because age places you at high risk for hypertension."
"A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.
"You have no need to worry. Your pressure is probably elevated because you are being tested."
The Correct Answer is C
A. "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination.": This response is premature as it assumes a diagnosis of hypertension based on a single elevated blood pressure reading without further assessment or confirmation.
B. "We will need to reevaluate your blood pressure because age places you at high risk for hypertension.": While age is a risk factor for hypertension, it is important not to jump to conclusions based on one blood pressure reading. Reevaluation and monitoring are necessary before making any definitive diagnoses or treatment decisions.
C. "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.": This response is appropriate because it acknowledges the need for further assessment and monitoring before determining if the client has hypertension. It also educates the client about the importance of multiple readings for an accurate diagnosis.
D. "You have no need to worry. Your pressure is probably elevated because you are being tested.": This response dismisses the client's concerns and does not provide accurate information about blood pressure assessment and hypertension diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Initiate a peripheral IV:
Initiating a peripheral intravenous (IV) line may be necessary for clients with unstable angina to facilitate the administration of medications and fluids, especially if there is a need for further interventions or if the client's condition deteriorates. However, in this case, the client's chest pain has improved after receiving nitroglycerin, and there is no immediate indication for IV access based on the information provided.
B. Administer another nitroglycerin tablet:
Nitroglycerin is a vasodilator commonly used to relieve chest pain (angina) by dilating blood vessels and improving blood flow to the heart. The initial response of the client's chest pain severity decreasing from 6 to 2 after one sublingual nitroglycerin tablet indicates a positive response to the medication. However, it's important to assess the client's response further before administering additional doses of nitroglycerin, especially considering the potential for hypotension or other adverse effects.
C. Call the Rapid Response Team:
The Rapid Response Team (RRT) is typically called in situations where there is a concern for a critical event or deterioration of a client's condition that requires immediate intervention. In this scenario, the client's chest pain has improved after nitroglycerin administration, and there are no indications of an acute critical event at this time. Therefore, calling the RRT is not warranted based on the client's current status.
D. Obtain an ECG:
An ECG can be helpful to assess for potential ischemia or other cardiac abnormalities. However, it's not the most urgent action when the client is responding positively to nitroglycerin. It can be done while monitoring the client's response to the second dose.
Correct Answer is ["B","C","D","E"]
Explanation
A. Take the medication with milk to increase absorption:
This statement is incorrect. Taking ferrous sulfate with milk or dairy products is not recommended as they can decrease iron absorption. It's advisable to take iron supplements with water or juice, preferably on an empty stomach or with a small amount of food.
B. Take the medication on an empty stomach:
This statement is partially correct. While taking ferrous sulfate on an empty stomach can enhance absorption, some individuals may experience gastrointestinal discomfort or irritation. Therefore, it's often recommended to take iron supplements with a small amount of food to minimize potential side effects.
C. Eat foods high in fiber while on this medication:
This statement is generally correct. Consuming foods high in fiber can help prevent constipation, which is a common side effect of iron supplements. Including fiber-rich foods in the diet, such as fruits, vegetables, whole grains, and legumes, can promote regular bowel movements.
D. Report stools that are dark in color immediately:
This statement is correct. Dark or black stools can indicate the presence of digested blood, which may occur due to iron supplementation. It's important to report such changes to the healthcare provider promptly for further evaluation.
E. Eating citrus fruit and juices are recommended with meals:
This statement is correct. Citrus fruits and juices, such as oranges, grapefruits, and lemon juice, contain vitamin C, which can enhance iron absorption. Consuming vitamin C-rich foods or drinks along with iron supplements can help improve iron uptake by the body.
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