A nurse is screening a community group for hypertension. Which person should be referred for immediate treatment?
A 20-year-old client who has a blood pressure of 125/60 mm Hg.
A 40-year-old client who has a blood pressure of 138/98 mm Hg.
A 55-year-old client who has a blood pressure of 142/68 mm Hg.
A 70-year-old client who has a blood pressure of 150/78 mm Hg.
The Correct Answer is B
A 40-year-old client who has a blood pressure of 138/98 mm Hg should be referred for immediate treatment. This is because this client has grade 1 hypertension according to the International Society of Hypertension (ISH) guidelines, which define hypertension as a systolic blood pressure (SBP) of 140 mm Hg or higher and/or a diastolic blood pressure (DBP) of 90 mm Hg or higher in the office or clinic. This client also has a high risk of cardiovascular complications due to their age and elevated DBP.
Choice A is wrong because a 20-year-old client who has a blood pressure of 125/60 mm Hg does not have hypertension. This client has normal blood pressure according to the ISH guidelines, which define normal blood pressure as an SBP of less than 130 mm Hg and a DBP of less than 85 mm Hg in the office or clinic. This client also has a low risk of cardiovascular complications due to their age and low DBP.
Choice C is wrong because a 55-year-old client who has a blood pressure of 142/68 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend lifestyle interventions for three to six months before medication in patients with grade 1 hypertension and no comorbidities.
This client may have other risk factors that need to be assessed, such as obesity, diabetes, or smoking, but they do not require urgent referral.
Choice D is wrong because a 70-year-old client who has a blood pressure of 150/78 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend a target blood pressure of less than 140/90 mm Hg within three months for patients older than 65 years, and after three months reduce the target to less than 130/80 mm Hg.
This client may have other risk factors that need to be assessed, such as chronic kidney disease, heart failure, or atrial fibrillation, but they do not require urgent referral.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client received a dose of clopidogrel at 2200. Clopidogrel is an antiplatelet drug that increases the risk of bleeding during and after a liver biopsy. The healthcare provider should be informed of this medication and decide whether to postpone the biopsy or administer reversal agents.
Choice A is wrong because being NPO since 2300 is a standard preparation for a liver biopsy.
Choice B is wrong because pain in the left lower quadrant and constipation are not related to the liver biopsy and do not pose an immediate risk.
Choice D is wrong because having an allergy is not relevant to the liver biopsy unless it is an allergy to the local anesthetic or contrast agent used.
Correct Answer is D
Explanation
“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.
Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.
Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.
Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.
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