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 A
Explanation
This is the most therapeutic response because it shows respect for the client’s autonomy and allows the nurse to explore the client’s concerns and feelings about the medication.
It also helps to establish trust and rapport with the client. Choice B. Report refusal to the charge nurse.
This is wrong because it does not address the client’s immediate needs and may make the client feel ignored or dismissed.
Choice C. Explain the purpose of the medication.
This is wrong because it may sound like lecturing or persuading the client, which can increase resistance and hostility.
Choice D. Encourage the client to take the medication.
This is wrong because it does not acknowledge the client’s right to refuse treatment and may imply that the nurse knows better than the client what is best for them.
Correct Answer is B
Explanation
This is the appropriate action because it prevents the spread of infection and maintains a clean environment.
The nurse should also wear gloves and dispose of the bag properly.
Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.
Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.
Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.
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