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 A

Explanation

(A) Heart murmur: This is the most appropriate answer. Mitral valve stenosis can cause a heart murmur due to turbulent blood flow across the narrowed mitral valve. This is often heard best at the apex of the heart with the patient in the left lateral decubitus position.

(B) Clubbing of the fingers: Clubbing of the fingers is typically associated with conditions that cause chronic hypoxia, such as lung disease or congenital heart disease. It is not a common finding in mitral valve stenosis.

(C) Bradycardia: Mitral valve stenosis does not typically cause bradycardia. In fact, some patients may have a rapid heart rate (tachycardia) due to atrial fibrillation, which is a common complication of mitral valve stenosis.

(D) Barrel chest: A barrel chest is typically associated with chronic obstructive pulmonary disease (COPD) and is not a common finding in mitral valve stenosis. It refers to a rounded, bulging chest that resembles the shape of a barrel. This occurs due to overinflation of the lungs over a long period of time.

A. Shiny, thin hairless skin on the lower extremities B. Dusky, red color of the feet when dangling C. Pitting edema D. Thickened toenails

Correct Answer is C

Explanation

(A) Re-collection of data: Re-collection of data is not the next step after planning. It might be done as part of the evaluation step or if there are significant changes in the client’s condition.

(B) Implementation: This is the most appropriate answer. After the planning step of the nursing process, the nurse moves on to the implementation step. This is where the nurse executes the interventions that were identified during the planning step.

(C) Data Collection: Data collection is typically the first step in the nursing process, where the nurse gathers information about the client’s health status. It is not the next step after planning.

(D) Evaluation: Evaluation is the final step of the nursing process. It involves assessing the client’s response to the nursing interventions and determining whether the client’s goals have been met. It is not the next step after planning.

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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 C

Explanation

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