A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse?
Measure the blood pressure in sitting and standing positions.
Measure the blood pressure in the left arm.
Document the findings in the medical record; elevated blood pressures are normal in older adults.
Immediately contact the medical provider.
None of the above.
The Correct Answer is B
Choice A reason: Measure the blood pressure in sitting and standing positions is not the next action by the nurse, as it is not relevant to the situation. The nurse should compare the blood pressure readings from both arms, not from different postures.
Choice B reason: Measure the blood pressure in the left arm is the next action by the nurse, as it can help determine if the high blood pressure is consistent or isolated to one arm. A difference of more than 10 mm Hg between the arms may indicate a vascular problem, such as atherosclerosis, aneurysm, or coarctation of the aorta.
Choice C reason: Document the findings in the medical record; elevated blood pressures are normal in older adults is not the next action by the nurse, as it is inaccurate and irresponsible. The nurse should not assume that elevated blood pressures are normal in older adults, as they may indicate hypertension, which is a risk factor for cardiovascular disease, stroke, and kidney damage. The nurse should also not document the findings without further assessment and intervention.
Choice D reason: Immediately contact the medical provider is not the next action by the nurse, as it may be premature and unnecessary. The nurse should first confirm the accuracy of the blood pressure readings by measuring the blood pressure in the left arm and checking the calibration of the device. The nurse should also consider other factors that may affect the blood pressure, such as pain, stress, caffeine, or medication.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the next action by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Can bring about long-term changes in lifestyle is true because persistent pain, also known as chronic pain, is pain that lasts for more than three months or beyond the expected healing time. Persistent pain can affect the physical, psychological, social, and emotional aspects of a person's life, and may require adjustments in daily activities, work, hobbies, relationships, and self-care.
Choice B reason: Is generally gone within 4 months is false because persistent pain does not have a clear end point and may persist for years or even a lifetime. Persistent pain is different from acute pain, which is pain that is sudden, sharp, and usually related to an injury or illness. Acute pain typically lasts for a short time and resolves when the underlying cause is treated.
Choice C reason: Is usually described as a burning pain is false because persistent pain can have various descriptions, depending on the cause, location, and intensity of the pain. Some common words that people use to describe persistent pain are aching, throbbing, stabbing, shooting, tingling, or numbness.
Choice D reason: Leads to significantly altered vital signs is false because persistent pain does not usually cause noticeable changes in vital signs, such as blood pressure, heart rate, respiratory rate, or temperature. This is because the body adapts to persistent pain over time and does not react as strongly as it does to acute pain. However, this does not mean that persistent pain is less severe or less important than acute pain.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Cognitive disorders are conditions that affect the mental functions, such as memory, reasoning, judgment, or orientation. Cognitive disorders can increase the risk of falls by impairing the awareness, attention, or decision-making of the client.
Choice B reason: Antibiotics are not a factor that requires particular attention when assessing a client who has a history of falls. Antibiotics are medications that treat bacterial infections, and they do not directly affect the risk of falls. However, some antibiotics may have side effects, such as dizziness, nausea, or diarrhea, that can indirectly increase the risk of falls.
Choice C reason: Orthostatic hypotension is a condition where the blood pressure drops significantly when changing position, such as standing up from sitting or lying down. Orthostatic hypotension can cause symptoms, such as lightheadedness, fainting, or blurred vision, that can increase the risk of falls.
Choice D reason: Vision is the sense of sight that allows the perception of the environment and the detection of potential hazards. Vision can decline with age or due to various eye diseases or injuries. Poor vision can increase the risk of falls by affecting the depth perception, contrast sensitivity, or visual field of the client.
Choice E reason: Balance is the ability to maintain the body's center of gravity over its base of support. Balance can be affected by various factors, such as inner ear problems, muscle weakness, joint stiffness, or medication use. Poor balance can increase the risk of falls by impairing the stability and coordination of the client.
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