A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

"Have you recently taken any antihistamines?"

"Have there been recent stressful events in your life?"

"Did you take any acetaminophen today?"

"Have you consistently taken your medications?"

Answer and Explanation

The Correct Answer is D

Choice D: This question is crucial as it addresses the client's adherence to their prescribed medication regimen for managing high blood pressure. Consistent medication use is essential for controlling blood pressure and reducing the risk of complications associated with hypertension. The elevated blood pressure reading suggests that the current medication regimen may not be effectively controlling the client's blood pressure. By assessing medication adherence, the nurse can determine if non-adherence is contributing to the high blood pressure reading or if adjustments to the medication regimen are required.

"Have you recently taken any antihistamines?": Asking about recent antihistamine use is not directly relevant to the client's high blood pressure reading of 210/106 mm Hg. Antihistamines are medications primarily used to relieve allergy symptoms and do not typically have a signiﬁcant impact on blood pressure levels.

"Have there been recent stressful events in your life?": While stress can contribute to temporary increases in blood pressure, asking about recent stressful events is not the most critical follow-up question in this situation. The client's blood pressure reading of 210/106 mm Hg indicates a severe elevation that requires immediate attention and management beyond stress reduction alone.

"Did you take any acetaminophen today?": Acetaminophen, also known as paracetamol, is a pain reliever and fever reducer. It does not typically have a signiﬁcant effect on blood pressure. Therefore, asking about acetaminophen use is not the most relevant follow-up question for the client's high blood pressure reading.

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Correct Answer is A

Explanation

Elevated levels of LDL (low-density lipoprotein) cholesterol are associated with an increased risk of coronary artery disease (CAD). LDL cholesterol is often referred to as "bad" cholesterol because it can contribute to the formation of plaque in the arteries, leading to narrowing and blockage of the arteries supplying the heart. This increases the risk of developing CAD and related complications such as heart attack and stroke.

On the other hand, HDL (high-density lipoprotein) cholesterol is often referred to as "good" cholesterol. HDL cholesterol helps remove excess cholesterol from the bloodstream and transport it back to the liver for processing and excretion. Higher levels of HDL cholesterol are associated with a decreased risk of CAD because it helps to prevent the accumulation of cholesterol on artery walls.

Therefore, understanding that increased LDL and decreased HDL levels increase the risk of coronary artery disease demonstrates a good understanding of the significance of cholesterol levels and their impact on cardiovascular health.

A. "I will avoid long periods of sitting down with my legs crossed over." B. "I will walk to the point of pain, rest, and walk again for at least 30 minutes." C. "I will use a heating pad on my feet at night to increase the circulation." D. "I will buy some loose clothes that do not bind across my legs or waist."

Correct Answer is C

Explanation

"I will use a heating pad on my feet at night to increase the circulation.": Using a heating pad on the feet at night is not recommended for clients with peripheral artery disease. The application of heat, such as from a heating pad, can dilate blood vessels and potentially worsen the symptoms of peripheral artery disease. This can lead to reduced blood flow to the affected limbs and increase the risk of complications.

The other client statements demonstrate an understanding of peripheral artery disease management:

"I will avoid long periods of sitting down with my legs crossed over." This statement shows awareness of the importance of maintaining good blood flow and avoiding positions that can restrict circulation.

"I will walk to the point of pain, rest, and walk again for at least 30 minutes." This statement indicates an understanding of the concept of intermittent claudication, a common symptom of peripheral artery disease. Walking until pain occurs, resting, and then resuming walking helps improve circulation and increases walking distance over time.

"I will buy some loose clothes that do not bind across my legs or waist." This statement reflects an awareness of the need to wear loose-fitting clothes that do not constrict blood flow to the legs or waist area.

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A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

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Naxlex Comprehensive Predictor Exams

The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement?

Correct Answer is A

Explanation

A nurse is teaching a client with chronic peripheral artery disease. What client statement indicates the need for further teaching?

Correct Answer is C

Explanation

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