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."

Answer and Explanation

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.

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Correct Answer is ["A","C","E"]

Explanation

A. Anxiety:

Anxiety can lead to an increased heart rate due to the activation of the sympathetic nervous system. When a person is anxious, their body releases stress hormones like adrenaline, which can stimulate the heart to beat faster. This increased sympathetic activity can cause sinus tachycardia, where the heart rate is faster than normal.

B. Sleep:

While sleep can affect heart rate variability, causing fluctuations in heart rate during different stages of sleep, it typically does not cause a significant and sustained increase in heart rate like sinus tachycardia. Sleep is more likely to influence heart rate patterns rather than directly cause sinus tachycardia.

C. Fever:

Fever, especially in response to infection or inflammation, can lead to an elevated heart rate. The body's response to fever includes increased metabolic activity, which can raise the heart rate as part of the physiological stress response. Fever-induced sinus tachycardia is a common finding in individuals with infections.

D. Hyperglycemia:

While hyperglycemia (high blood sugar levels) can have cardiovascular effects over time, such as contributing to atherosclerosis and heart disease, it is not typically a direct cause of sinus tachycardia. Sinus tachycardia is more commonly associated with acute stressors like anxiety, fever, or hypovolemia (such as from blood loss).

E. Blood loss:

Significant blood loss, such as during surgery or due to trauma, can result in hypovolemia, where there is a decrease in blood volume circulating in the body. In response to hypovolemia, compensatory mechanisms kick in, including an increase in heart rate (sinus tachycardia), to maintain blood pressure and perfusion to vital organs.

A. The blood was infused too quickly and overwhelmed the client's circulatory system. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. Antibodies to donor leukocytes remained in the blood.

Correct Answer is B

Explanation

A. The blood was infused too quickly and overwhelmed the client's circulatory system:

While infusing blood too quickly can lead to circulatory overload and related complications like heart failure or pulmonary edema, it is not the cause of an acute hemolytic transfusion reaction. Acute hemolytic reactions occur due to immune responses against incompatible donor blood.

B. The donor blood was incompatible with that of the client:

This is the correct answer. An acute hemolytic transfusion reaction happens when there is an incompatibility between the donor's blood and the recipient's blood. This can occur due to mismatched ABO blood types or Rh factor, leading to the recipient's immune system attacking and destroying the transfused red blood cells.

C. The client had a sensitivity reaction to a plasma protein in the blood:

Sensitivity reactions to plasma proteins can occur, but they typically result in different types of transfusion reactions, such as allergic reactions or febrile non-hemolytic reactions. These reactions are caused by antibodies to specific plasma proteins and are not the cause of acute hemolytic transfusion reactions.

D. Antibodies to donor leukocytes remained in the blood:

This option refers to febrile non-hemolytic transfusion reactions, which occur due to antibodies against donor leukocytes. However, this type of reaction is distinct from acute hemolytic reactions, which are primarily caused by ABO or Rh incompatibility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Correct Answer is ["A","C","E"]

Explanation

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?

Correct Answer is B

Explanation

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