A nurse is providing discharge instruction to a client who has hypertension that has resulted in a transient ischemic attack (TIA). Which of the following information should the nurse discuss with the client regarding blood pressure (BP) management?
The client should maintain systolic BP between 120 and 129 mm Hg.
The client should maintain systolic BP between 130 and 135 mm Hg.
The client should maintain systolic BP between 136 and 140 mm Hg.
The client should maintain systolic BP between 141 and 145 mm Hg.
Note the time the seizure started
The Correct Answer is A
A. The client should maintain systolic BP between 120 and 129 mm Hg.
This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.
B. The client should maintain systolic BP between 130 and 135 mm Hg.
This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.
C. The client should maintain systolic BP between 136 and 140 mm Hg.
This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
D. The client should maintain systolic BP between 141 and 145 mm Hg.
This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lie flat:
This option involves instructing the patient to lie flat on their back without elevating their head. Lying flat helps to maintain consistent pressure in the spinal canal, reducing the likelihood of CSF leakage from the puncture site. This position is commonly recommended after a lumbar puncture to prevent or minimize the occurrence of post-lumbar puncture headaches (PLPH).
B. Lie on left side:
This option involves instructing the patient to lie on their left side. While lying on the left side may provide some relief by reducing pressure on the lumbar puncture site, it is not typically recommended immediately after the procedure to prevent PLPH. Lying flat is generally preferred to minimize changes in CSF pressure and reduce the risk of headache.
C. Stay in semi-Fowler position:
The semi-Fowler position involves elevating the head of the bed at a 30-45 degree angle. This position is not typically recommended immediately after a lumbar puncture because it may increase CSF leakage and pressure changes, potentially exacerbating the risk of developing a headache.
D. Ambulate in the room with assistance:
Ambulating shortly after a lumbar puncture is not typically recommended as it may increase the risk of developing a headache. Movement and changes in posture can exacerbate CSF leakage and pressure changes at the puncture site, leading to the development of post-lumbar puncture headaches.
Correct Answer is A
Explanation
A. Orthostatic hypotension:
Orthostatic hypotension, a sudden drop in blood pressure when standing up, is a potential adverse effect of levodopa therapy. This can lead to dizziness and increase the risk of falls, thus supporting the nursing diagnosis Risk for Injury.
B. Nausea and vomiting:
Nausea and vomiting are common side effects of levodopa therapy. While they can cause discomfort and dehydration, they are less directly related to the risk of physical injury compared to orthostatic hypotension.
C. Anorexia and depression:
Anorexia (loss of appetite) and depression can occur as adverse effects of levodopa therapy. While they can affect the patient's overall well-being and quality of life, they are not directly associated with an increased risk of physical injury.
D. Tachycardia and palpitations:
Tachycardia (rapid heart rate) and palpitations are less common adverse effects of levodopa therapy. While they may indicate cardiovascular issues, they are not typically associated with a direct risk of physical injury.
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