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
The RR interval is 7.5 big boxes, multiplied by 10 makes it 75, rounded off is 80 beats per minute.
Correct Answer is A
Explanation
A. "Only take one nitroglycerin tablet for each episode of angina."
This instruction is correct. Sublingual nitroglycerin is typically administered as needed for the relief of angina symptoms, with one tablet being the initial dose. If the chest pain persists after 5 minutes, the client may take a second tablet, and if needed, a third tablet after another 5 minutes. However, if the pain is not relieved after three tablets, they should seek immediate medical attention.
B. "Place the nitroglycerin tablet between cheek and gum."
This instruction is incorrect. Sublingual nitroglycerin tablets should be placed under the tongue, allowing them to dissolve and be absorbed directly into the bloodstream. Placing the tablet between the cheek and gum is not the recommended administration route for sublingual nitroglycerin.
C. "Call 911 if you develop a headache following nitroglycerin use."
This instruction is partially correct. Headache is a common side effect of nitroglycerin due to its vasodilatory effects. Clients should be informed about this potential side effect, but not every headache following nitroglycerin use requires immediate medical attention. However, if the headache is severe, persistent, or accompanied by other concerning symptoms, the client should seek medical evaluation.
D. "See if rest relieves the chest pain before using the nitroglycerin."
This instruction is incorrect. Sublingual nitroglycerin is a rapid-acting medication used to relieve angina symptoms quickly. Clients should not delay taking nitroglycerin and wait for rest to relieve chest pain, as this can lead to worsening symptoms and complications.
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