A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/74 mm Hg places him in which of the following categories or stages?

Hypertension stage 2

Elevated or Prehypertension

Hypertension stage 1

Within the expected reference range

Answer and Explanation

The Correct Answer is B

A. Hypertension stage 2: Hypertension stage 2 is defined as a systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg. The client’s reading of 124/74 mm Hg does not fall into this category.

B. Elevated or Prehypertension: A systolic blood pressure between 120-129 mm Hg and a diastolic <80 mm Hg is classified as elevated or prehypertension. The client’s systolic BP of 124 mm Hg places him in this category.

C. Hypertension stage 1: Hypertension stage 1 is defined as a systolic BP between 130-139 mm Hg or diastolic BP between 80-89 mm Hg. The client’s BP of 124/74 mm Hg does not meet this criterion.

D. Within the expected reference range: The normal range for blood pressure is less than 120/80 mm Hg. The client’s BP of 124/74 mm Hg is slightly elevated and does not fall within the expected reference range.

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Correct Answer is B

Explanation

A. 108/60 mm Hg: This is considered normal blood pressure and does not indicate hypertension.

B. 134/86 mm Hg: According to the current guidelines, stage 1 hypertension is defined as systolic 130-139 mm Hg or diastolic 80-89 mm Hg. This client's blood pressure falls into that category.

C. 164/104 mm Hg: This is classified as stage 2 hypertension, which is defined by systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg.

D. 128/68 mm Hg: This is considered elevated blood pressure, not stage 1 hypertension. Stage 1 begins at systolic BP of 130 mm Hg.

A. "The client may benefit from a neurology consult." B. "The client is disoriented and pupils are slow to respond to light." C. "The client has developed drooping facial features." D. "The client has a history of hypertension."

Correct Answer is D

Explanation

A. "The client may benefit from a neurology consult." This statement is more appropriate for the recommendation component of SBAR. The background should focus on what has already occurred or is known, not what the nurse thinks should be done next.

B. "The client is disoriented and pupils are slow to respond to light." This would be part of the assessment component of SBAR, which describes the nurse's evaluation of the current condition.

C. "The client has developed drooping facial features." This statement can be included in theSituationcomponent because it describes the immediate concern that prompted the communication.

D. "The client has a history of hypertension." This statement is suitable for theBackgroundcomponent. It provides relevant medical history that helps the provider understand the context of the current situation.

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A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/74 mm Hg places him in which of the following categories or stages?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

Correct Answer is D

Explanation

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