The nurse is screening for hypertension at a local health fair.
A community resident has a blood pressure reading of 138/80 mm Hg. What interventions should the nurse implement for this client? Select all that apply.
Encourage the client to “keep doing whatever you are doing.”.
Assess the client’s lifestyle and other risk factors for hypertension.
Ask the client about any current antihypertensive medications.
Obtain another blood pressure reading to verify the first reading.
Recommend further evaluation for possible pre-hypertension.
Correct Answer : B,C,D,E
Answer and explanation
The correct answers are Choices B, C, D, and E.
Choice A rationale
Encouraging the client to “keep doing whatever you are doing” is not an appropriate intervention for a client with a blood pressure reading of 138/80 mm Hg. This blood pressure reading is considered elevated and could indicate pre-hypertension. Therefore, the nurse should assess the client’s lifestyle and other risk factors for hypertension, ask the client about any current antihypertensive medications, obtain another blood pressure reading to verify the first reading, and recommend further evaluation for possible pre-hypertension.
Choice B rationale
Assessing the client’s lifestyle and other risk factors for hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Lifestyle factors, such as diet, physical activity, alcohol consumption, and tobacco use, can significantly influence
blood pressure levels. Therefore, the nurse should assess these factors and provide appropriate education and interventions.
Choice C rationale
Asking the client about any current antihypertensive medications is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. The client may be taking medications that could affect their blood pressure. Therefore, the nurse should ask about these medications and consider their potential impact on the client’s blood pressure.
Choice D rationale
Obtaining another blood pressure reading to verify the first reading is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Blood pressure can fluctuate throughout the day and can be influenced by various factors, such as stress, physical activity, and caffeine consumption. Therefore, the nurse should obtain another reading to confirm the initial measurement.
Choice E rationale
Recommending further evaluation for possible pre-hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. A blood pressure reading of 138/80 mm Hg is considered elevated and could indicate pre-hypertension. Therefore, the nurse should recommend further evaluation to confirm this diagnosis and determine appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer and explanation
The correct answer is C.
Choice A rationale
Patches of round lesions on both lower legs could be a sign of a skin condition such as ringworm. However, this condition is typically not urgent and can be treated with over-the- counter antifungal creams.
Choice B rationale
Red ring-shaped lesions with normal skin in the center could be a sign of ringworm. While this condition should be treated, it is not typically considered urgent.
Choice C rationale
Itchy, red, scaly patches with blisters that are draining could be a sign of a serious skin infection such as cellulitis. This condition can spread quickly and become serious if not treated promptly, so it should be prioritized for immediate intervention.
Choice D rationale
Several irritated circular bald, flaky scalp patches could be a sign of a scalp condition such as tinea capitis. While this condition should be treated, it is not typically considered urgent.
Correct Answer is A
Explanation
Answer and explanation
The correct answer is Choice A.
Choice A rationale
Anthrax is a serious disease caused by Bacillus anthracis, a bacterium that forms spores. Certain occupations, such as those involving livestock or animal products, may increase the risk of exposure to anthrax spores.
Choice B rationale
While it’s important to identify personal contacts in the case of some infectious diseases, anthrax is not spread from person to person. Therefore, identifying personal contacts over the past week would not necessarily help to rule out exposure to anthrax spores.
Choice C rationale
A twenty-four-hour diet history would not typically be useful in ruling out exposure to anthrax spores. Anthrax is not usually spread through food or water.
Choice D rationale
Inquiring about previous vaccination for smallpox would not help to rule out exposure to anthrax spores. Smallpox and anthrax are caused by different organisms, and the smallpox vaccine does not provide protection against anthrax.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.