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 D

Explanation

A. Valve disorder: While valve disorders can cause fatigue and dyspnea, the client’s history of hypertension, tachycardia, hypercholesteremia, and medication noncompliance are more suggestive of heart failure rather than a valve disorder.

B. Asthma: Asthma typically presents with wheezing, shortness of breath, and chest tightness. It is less likely to be the cause of symptoms in this scenario, where cardiac conditions and medication noncompliance are noted.

C. Pulmonary embolism: While pulmonary embolism can cause dyspnea and tachycardia, the client's chronic cardiovascular history and edema are more consistent with heart failure than an acute pulmonary embolism.

D. Heart failure: The client has a history of hypertension, tachycardia, and hypercholesteremia, along with medication noncompliance, tachycardia, and edema. These are classic signs of heart failure, making this the most likely diagnosis

A. Popliteal B. Brachial C. Femoral D. Carotid

Correct Answer is D

Explanation

A. Popliteal: Checking the popliteal pulse bilaterally is generally safe, as it does not carry the risk of compromising blood flow to the brain.

B. Brachial: Checking the brachial pulse bilaterally is safe and does not compromise circulation to vital organs.

C. Femoral: The femoral pulse can be checked bilaterally without causing significant issues.

D. Carotid: Checking the carotid pulse bilaterally can reduce blood flow to the brain and lead to syncope (fainting), so it should be avoided. Palpating one carotid artery at a time is the correct approach.

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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

Correct Answer is D

Explanation

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

Correct Answer is D

Explanation

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