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A group of student nurses are practicing taking blood pressures. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, “My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?” Which of the following responses by the nursing instructor would be best?

“A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made.”

“We will need to reevaluate your blood pressure because your age places you at high risk for hypertension.”

“Hypertension is prevalent among men: it is fortunate we caught this during your routine examination.”

“You have no need to worry. Your pressure is probably elevated because you are being tested.”

Answer and Explanation

The Correct Answer is A

A. "A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made."

This response emphasizes the need for multiple elevated readings for a diagnosis of hypertension. It educates the individual about the diagnostic criteria and encourages them to seek further evaluation from their physician.

B. "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension."

This response might be seen as implying that age alone is a significant factor in determining hypertension, which may not be accurate. While age is a risk factor, the emphasis should be on the need for multiple readings and a physician's evaluation rather than attributing it solely to age.

C. "Hypertension is prevalent among men: it is fortunate we caught this during your routine examination."

This response suggests that the elevated blood pressure is automatically assumed to be hypertension based on gender. It is important to avoid making assumptions and instead focus on the need for proper evaluation and multiple readings for a hypertension diagnosis.

D. "You have no need to worry. Your pressure is probably elevated because you are being tested."

This response dismisses the individual's concerns and attributes the elevated blood pressure solely to the testing situation. While stress or anxiety can influence blood pressure readings, it's essential to address the need for further evaluation and not completely disregard the possibility of hypertension.

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Correct Answer is A

Explanation

A. Frequent change of position:

Frequent changes in position help prevent pooling of secretions and promote lung expansion. This simple and cost-effective measure is important in preventing complications related to immobility, such as pneumonia and atelectasis. It aids in maintaining optimal respiratory function.

B. Antibiotics: Antibiotics are used to treat bacterial infections and would not directly address the risks associated with decreased mobility.

C. Oxygen humidification: While oxygen therapy may be necessary in some cases, humidification is typically used to prevent drying of mucous membranes and is not a primary intervention for preventing complications of decreased mobility.

D. Chest physiotherapy: Chest physiotherapy involves techniques to mobilize respiratory secretions and may be indicated in specific situations. However, it is not as simple and cost-effective as frequent changes in position.

A. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage B. Use of strategies to prevent falls stemming from postural hypotension C. Limiting exercise to avoid injury that can be caused by increased intracranial pressure D. Increasing fluids to avoid extracellular volume depletion from the diuretic effects of the beta-blocker

Correct Answer is B

Explanation

A. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage

Explanation: This statement is not accurate. While a balanced diet is important, there is no specific recommendation to maintain a diet high in dairy to prevent organ damage related to hypertension.

B. Use of strategies to prevent falls stemming from postural hypotension

Explanation: This is a correct and important consideration. Beta-blockers can cause postural hypotension (a drop in blood pressure upon standing), and strategies to prevent falls, such as rising slowly from a sitting or lying position, are crucial.

C. Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Explanation: This statement is not accurate. Exercise is generally beneficial for individuals with hypertension, and beta-blockers do not cause increased intracranial pressure.

D. Increasing fluids to avoid extracellular volume depletion from the diuretic effects of the beta-blocker

Explanation: This statement is not accurate. Beta-blockers are not typically associated with diuretic effects. Diuretics are a different class of medications commonly used for hypertension.

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The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

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Correct Answer is B

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