Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Intermittent claudication:

Intermittent claudication is more commonly associated with peripheral arterial insufficiency rather than venous insufficiency. It is caused by inadequate blood flow to the muscles during activity, resulting in cramping or pain that typically resolves with rest.

B. Brownish discoloration to the legs:

Brownish discoloration to the legs, often referred to as hemosiderin staining, is a common finding in peripheral venous insufficiency. It occurs due to the breakdown of red blood cells and the deposition of hemosiderin in the tissues, especially around the ankles.

C. Weak or absent pedal pulses:

Weak or absent pedal pulses are more indicative of peripheral arterial insufficiency rather than venous insufficiency. Peripheral arterial disease can result in decreased blood flow to the extremities, leading to diminished pulses.

D. Unequal peripheral pulses between extremities:

Unequal peripheral pulses between extremities are also more suggestive of arterial insufficiency. Conditions such as atherosclerosis or arterial embolism can cause variations in pulses between different limbs.

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex. B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema. C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue. D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

Correct Answer is D

Explanation

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.

This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.

B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.

Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.

C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.

While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.

D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following does the nurse recognize is common in peripheral venous insufficiency?

Correct Answer is B

Explanation

The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?

Correct Answer is D

Explanation

The physician orders warfarin (Coumadin) 10 mg PO to be administered to a client at 1800 today. The pharmacy only has 2.5 mg tablets available. How many tablets will the nurse administer?

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?

A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally: 3 pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

An older adult is newly diagnosed with primary hypertension, and has just been started on a beta-blocker. What information should the nurse include in the health education for this client?

The nurse is taking health history for a client who reports pain in his lower left leg and foot when walking. The pain is relieved with rest, and the nurse observes the left leg is hairless and slightly edematous. The nurse recognizes this as which medical diagnosis or health problem?

A community health nurse teaches a group of seniors at an assisted living facility about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements?