A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

Request that another nurse check the client's BP in 30 min.

Reposition the client supine and recheck her BP.

Recheck the client's BP in her other arm for comparison.

Ensure that the width of the BP cuff is 50% of the client's upper arm circumference

Answer and Explanation

The Correct Answer is C

A. Request that another nurse check the client's BP in 30 min:

Waiting for 30 minutes to have another nurse check the blood pressure may not be the most immediate and effective action. If there are concerns about the accuracy of the reading, rechecking the BP in the other arm promptly is a more appropriate and efficient approach.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary in this context. Blood pressure can be accurately measured while the client is sitting. Changing the position might not provide relevant information about the accuracy of the blood pressure reading.

C. Recheck the client's BP in her other arm for comparison:

This is the appropriate action. Checking the blood pressure in the other arm can help determine if there is a significant difference between the arms. A significant difference could indicate arterial disease or other issues. It's essential to confirm the accuracy of the blood pressure measurement.

D. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While ensuring the appropriate size of the BP cuff is essential for accurate readings, this option is not directly addressing the current situation of an elevated blood pressure reading. Checking the other arm for comparison is more relevant to assess the accuracy of the measurement.

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Correct Answer is D

Explanation

A. The nurse's empathy about the client having to self-inject:

While empathy is important for building a therapeutic relationship, the client's motivation to learn is more likely to be influenced by factors directly related to their own needs and perceived benefits.

B. The client seeking family approval by agreeing to a teaching plan:

External factors, such as seeking family approval, may influence a client's willingness to participate in a teaching plan, but they might not be as effective in sustaining motivation over the long term. Intrinsic motivation tends to be more enduring and impactful.

C. The nurse explaining the need for education to the client:

While explaining the need for education is important, the client's motivation may be more influenced by their personal beliefs about the benefits of learning and meeting their own needs rather than an external explanation.

D. The client's belief that his needs will be met through education:

This statement reflects the client's intrinsic motivation, where the client perceives that learning to self-administer daily low-dose heparin injections will meet his needs. Intrinsic motivation is a powerful driver for learning because it comes from within the individual.

A. "Tell me more about your partner." B. "Have you thought about harming yourself?" C. "Why did you stop taking your medication? D. "You should discuss these feelings with your provider."

Correct Answer is B

Explanation

A. "Tell me more about your partner.":

While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.

B. "Have you thought about harming yourself?":

This response is appropriate because it directly addresses the client's statement expressing a desire to die. It opens a dialogue about the client's thoughts and intentions related to self-harm, allowing the nurse to assess the client's risk and initiate appropriate interventions.

C. "Why did you stop taking your medication?":

While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.

D. "You should discuss these feelings with your provider.":

This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.

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A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is D

Explanation

A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse. "I want to die now that my partner is gone." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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