A nurse is assisting with a presentation on health promotion activities for clients who have hypertension. Which of the following should the nurse utilize as a resource for this information?

A critical pathway for clients who have had a stroke

Standards of care for monitoring clients who have a history of blood pressure elevation

Acute care facility protocols for clients experiencing an abrupt change in mental status

Clinical practice guidelines for the management of high blood pressure

Answer and Explanation

The Correct Answer is D

A. A critical pathway for clients who have had a stroke:
Critical pathways are structured multidisciplinary care plans that outline essential steps in the care of patients with specific conditions. While critical pathways are valuable tools for standardized care, they are not specifically focused on health promotion activities for clients with hypertension.

B. Standards of care for monitoring clients who have a history of blood pressure elevation:
Standards of care typically outline the minimum level of care that should be provided to clients based on evidence-based practice. While monitoring clients with a history of blood pressure elevation is important, it does not encompass the comprehensive health promotion activities related to hypertension.

C. Acute care facility protocols for clients experiencing an abrupt change in mental status:
Acute care facility protocols are designed to guide the management of acute changes in a patient's condition. While relevant to patient care, these protocols do not specifically address health promotion activities for clients with hypertension.

D. Clinical practice guidelines for the management of high blood pressure:
Clinical practice guidelines provide evidence-based recommendations for the management of specific health conditions. They typically include information on health promotion activities, risk factor modification, lifestyle interventions, and pharmacological management for clients with hypertension. Therefore, clinical practice guidelines are the most appropriate resource for information on health promotion activities for clients with hypertension.

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Correct Answer is B

Explanation

A. Moist mucous membranes: Moist mucous membranes are typically a sign of good hydration and are not usually associated with end-of-life stages. In fact, patients nearing the end of life often experience dryness of the mouth and mucous membranes due to decreased fluid intake and certain medications. This dryness can lead to discomfort and difficulties in swallowing or speaking, which is why oral care is an important part of end-of-life care.

B. Irregular respirations: This is correct. As the body’s systems start to shut down in the final stages of life, irregular respirations, including periods of rapid breathing and pauses (Cheyne-Stokes respirations), can be a common symptom. This happens because the body can no longer effectively remove carbon dioxide, and the automatic process of breathing becomes less coordinated. This can be distressing to witness, but it’s usually not uncomfortable for the patient.

C. Tachycardia: While some patients may experience changes in heart rate, tachycardia is not typically a consistent finding in patients at the end of life. As the body weakens, the heart has to work harder to pump blood, which can sometimes lead to a faster heart rate. However, as the end of life approaches, the heart rate often slows down, and blood pressure decreases.

D. Hypertension: Hypertension, or high blood pressure, is not typically a symptom associated with end-of-life care. In the final stages of life, the body’s systems begin to slow down, and blood pressure often decreases. This is due to a combination of factors, including a slower heart rate and a decrease in the body’s ability to regulate blood pressure. It’s also worth noting that pain, anxiety, and certain medications can temporarily increase blood pressure, even in the end-of-life stages.

A. Dry skin B. Diarrhea C. Hyperventilation D. Abdominal pain

Correct Answer is C

Explanation

A. Dry skin:

Dry skin is not typically associated with respiratory alkalosis. Instead, it may occur in conditions such as dehydration or impaired skin integrity.

B. Diarrhea:

Diarrhea is not typically associated with respiratory alkalosis. Respiratory alkalosis primarily involves changes in the respiratory system, leading to alterations in blood pH and carbon dioxide levels.

C. Hyperventilation:

Hyperventilation is a characteristic finding in respiratory alkalosis. It is a compensatory mechanism where the client breathes rapidly and deeply to blow off excess carbon dioxide, attempting to restore acid-base balance.

D. Abdominal pain:

Abdominal pain is not typically associated with respiratory alkalosis. While some individuals with respiratory alkalosis may experience symptoms such as dizziness, lightheadedness, or tingling sensations, abdominal pain is not a common manifestation of this acid-base imbalance.

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A nurse is assisting with a presentation on health promotion activities for clients who have hypertension. Which of the following should the nurse utilize as a resource for this information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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