During a health screening, a patient's blood pressure is confirmed by two clinic nurses to be 220/120 mm Hg. Which of the following actions should the nurse recommend to the patient?
“Take off work for the rest of the day to rest at home."
"Return to work and have your blood pressure rechecked in 2 days."
"Take two doses of blood pressure medication right now."
"Sit quietly while we call 911 to request an ambulance."
The Correct Answer is D
A. “Take off work for the rest of the day to rest at home.": This advice is not adequate for such a high blood pressure reading, which indicates a hypertensive crisis that requires immediate medical intervention.
B. "Return to work and have your blood pressure rechecked in 2 days.": This is inappropriate as it delays necessary urgent medical evaluation and treatment.
C. "Take two doses of blood pressure medication right now.": Without medical supervision, this could be dangerous and is not appropriate in an emergency situation where the blood pressure is critically high.
D. "Sit quietly while we call 911 to request an ambulance.": A blood pressure of 220/120 mm Hg suggests a hypertensive emergency, which can lead to life-threatening complications like stroke or heart attack. The patient needs immediate medical attention, and calling 911 is the appropriate response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Have the patient lie in bed with a pillow under the knees: Elevation of the legs can reduce blood flow to the feet, worsening symptoms. Additionally, putting a pillow under the knees can compress arteries further, exacerbating ischemia.
B. Evaluate the distal pulses: Assessing the distal pulses is crucial for determining the severity of blood flow impairment and helps in understanding the extent of peripheral arterial disease.
C. Cover the patient with a blanket: While warmth might provide some comfort, it does not address the underlying vascular issue and is not a primary intervention for this condition.
D. Notify the physician: While it may be necessary eventually, evaluating the patient's distal pulses first will provide critical information that the nurse can report to the physician.
Correct Answer is A
Explanation
Correct answer: A
A. Monitoring for infection: Infection is a significant risk with external fixation devices due to the presence of pins that penetrate the skin and soft tissues. Monitoring for signs of infection, such as redness, swelling, discharge, or increased pain, is crucial.
B. Monitoring circulatory status: While circulatory status is important, especially in cases of limb injury or immobilization, it is not the most immediate concern compared to the risk of infection from the external fixation device.
C. Validating proper mobility: Ensuring proper mobility is important, but it is secondary to the prevention and detection of infection. Mobility assessments can be done after confirming that there are no infections or complications.
D. Checking discomfort level: While assessing discomfort is important for pain management and comfort, it is not as critical as monitoring for infection, which can lead to severe complications if not addressed promptly.
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