A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
"I will wait 15 minutes after drinking coffee to measure my blood pressure."
"I will measure my blood pressure while my arm is elevated above my heart."
"I should remove constrictive clothing prior to measuring my blood pressure."
"I should measure my blood pressure immediately after eating breakfast.”
The Correct Answer is C
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: "Instruct the client to tilt their head forward while eating."
Choice A rationale:
Offering the client a straw to drink liquids might not be suitable for someone with dysphagia following a stroke. Straws can sometimes contribute to aspiration risk, especially if the client has difficulty controlling their swallowing reflex. Using a straw might lead to aspiration of liquids, which can be dangerous for the client's respiratory health.
Choice B rationale:
Placing food toward the back of the client's mouth could increase the risk of choking and aspiration, especially if the client has difficulty swallowing due to dysphagia. It's important to place small bites of food at the front of the mouth and encourage slow, controlled chewing and swallowing to reduce the risk of aspiration.
Choice C rationale:
Encouraging the client to lie down and rest for 30 minutes after meals is not a recommended intervention for someone with dysphagia. This position can actually increase the risk of aspiration. The client should be in an upright position while eating and for some time after eating to allow gravity to assist in preventing aspiration.
Choice D rationale:
Instructing the client to tilt their head forward while eating helps to facilitate safer swallowing by preventing food from entering the airway. This posture helps direct the food toward the esophagus and reduces the risk of aspiration. It's an essential technique for clients with dysphagia to maintain their airway safety while eating.
Correct Answer is D
Explanation
The correct answer is choice d. Notify the charge nurse of the client’s concerns.
Choice A rationale:
Offering information about alternative therapies is not appropriate in this situation. The nurse’s role is to ensure the client understands the current procedure and to address their concerns, not to suggest alternatives unless directed by the healthcare provider.
Choice B rationale:
Contacting a family member to convince the client to change their mind is not ethical. The decision to proceed with surgery should be made by the client, based on their understanding and consent, not under pressure from family members.
Choice C rationale:
Telling the client the benefits of the surgery might be helpful, but it does not address the client’s lack of understanding about the procedure. The nurse should ensure the client has all the necessary information to make an informed decision.
Choice D rationale:
Notifying the charge nurse of the client’s concerns is the correct action. The charge nurse can facilitate further discussion with the surgeon to ensure the client receives the necessary information and support to make an informed decision. This ensures that the client’s autonomy and right to informed consent are respected.
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