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 D
Explanation
Diminished breath sounds in a client admitted with pneumonia. This is because diminished breath sounds indicate a worsening of the respiratory condition and a possible complication of pneumonia, such as atelectasis or pleural effusion.
The healthcare provider should be notified immediately to assess the client and order appropriate interventions.
Choice A is wrong because a report of joint pain by a client who recently started taking arthritis medication is not an urgent finding.
Joint pain is a common symptom of arthritis and may take some time to improve with medication.
The nurse should monitor the client’s pain level and administer analgesics as prescribed.
Choice B is wrong because report of decreased appetite and difficulty sleeping is not an immediate concern.
These are nonspecific symptoms that may be related to stress, anxiety, depression, or other factors.
The nurse should explore the possible causes of these symptoms and provide emotional support and education to the client.
Choice C is wrong because a weight loss of two pounds in a client admitted to congestive heart failure is not a critical finding.
Weight loss may indicate a reduction of fluid retention, which is a desired outcome for clients with heart failure.
The nurse should monitor the client’s weight daily and report any significant changes to the health care provider.
Normal ranges for weight, appetite, sleep, joint pain, and breath sounds vary depending on the individual’s age, gender, height, activity level, medical history, and other factors.
Correct Answer is B
Explanation
The client on Digitalis has a low potassium level of 3.0 mEq/L, below the normal range of 3.5-5.0 mEq/L. Low potassium levels can increase the risk of digitalis toxicity, which can cause nausea, abdominal discomfort, visual changes, and cardiac arrhythmias.
The nurse would instruct the client to eat foods high in potassium, such as cantaloupe, to prevent or correct hypokalemia.
Choice A. Asparagus is wrong because asparagus is a low-potassium food that contains only 202 mg of potassium per cup.
Eating asparagus would not help to raise the client’s potassium level.
Choice C. Blackberries are wrong because blackberries are also a low-potassium food that contains only 233 mg of potassium per cup.
Eating blackberries would not help to raise the client’s potassium level.
Choice D. Cucumbers is wrong because cucumbers are a very low-potassium food that contains only 76 mg of potassium per cup.
Eating cucumbers would not help to raise the client’s potassium level and may even lower it further.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today