A client has been treated for hypertension.
What blood pressure reading indicates to the nurse that the treatment is effective?
84/50 mmHg.
120/77 mmHg.
148/88 mmHg.
160/90 mmHg.
The Correct Answer is B
120/77 mmHg. This is because this blood pressure reading is within the normal range of less than 120/80 mmHg. Hypertension is defined as a blood pressure of 140/90 mmHg or higher.
Choice A is wrong because 84/50 mmHg is too low and may indicate hypotension, which can cause dizziness, fainting, or shock.
Choice C is wrong because 148/88 mmHg is above the normal range and indicates prehypertension, which is a risk factor for developing hypertension and cardiovascular disease.
Choice D is wrong because 160/90 mmHg is above the normal range and indicates stage 1 hypertension, which requires treatment with lifestyle changes and medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Administer oxygen. This is the first priority because oxygen can help prevent further sickling of red blood cells and improve tissue perfusion.
B. Start IV fluids. This is the second priority because hydration can reduce blood viscosity and prevent vaso-occlusion.
C. Administer pain medication. This is the third priority because pain is a common and distressing symptom of sickle cell crisis and should be treated with opioids around the clock.
D. Draw lab work. This is the last priority because lab work can help monitor the severity of the crisis and the need for blood transfusions, but it does not directly relieve the patient’s symptoms or prevent complications.
Correct Answer is B
Explanation
Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy
treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.
According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).
Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.
Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.
Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.
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