The nurse who is providing instructions to a client with hypertension will stress that it is most important to:
increase calcium in the diet.
obtain blood pressure checks twice a year.
monitor weight on a weekly basis.
get regular physical activity.
The Correct Answer is D
Choice A reason: Increasing calcium in the diet is not the most important instruction for a client with hypertension. Calcium is a mineral that helps maintain bone health and muscle contraction, but it does not have a significant effect on blood pressure. The nurse should advise the client to limit sodium, fat, and alcohol intake, and to eat more fruits, vegetables, and whole grains.
Choice B reason: Obtaining blood pressure checks twice a year is not the most important instruction for a client with hypertension. This frequency is too low for a client who has a chronic condition that requires close monitoring and treatment. The nurse should advise the client to check their blood pressure regularly, preferably at home, and to report any abnormal readings to their health care provider.
Choice C reason: Monitoring weight on a weekly basis is not the most important instruction for a client with hypertension. Weight is a factor that can influence blood pressure, but it is not the only one. The nurse should advise the client to maintain a healthy weight and to lose weight if they are overweight or obese, but not to focus on the scale alone.
Choice D reason: Getting regular physical activity is the most important instruction for a client with hypertension. Physical activity can lower blood pressure by strengthening the heart, improving blood circulation, reducing stress, and preventing or managing other risk factors, such as obesity, diabetes, and high cholesterol. The nurse should advise the client to engage in moderate aerobic exercise for at least 30 minutes a day, five days a week, and to consult their health care provider before starting any new exercise program.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Respiratory alkalosis is not the correct answer. Respiratory alkalosis is a condition where the blood pH is high (above 7.45) due to low carbon dioxide levels (below 35 mmHg) caused by hyperventilation. The client's blood pH is low (7.2) and the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory alkalosis.
Choice B reason: Metabolic alkalosis is not the correct answer. Metabolic alkalosis is a condition where the blood pH is high (above 7.45) due to high bicarbonate levels (above 26 mEq/L) caused by excessive loss of acids or intake of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which does not indicate metabolic alkalosis.
Choice C reason: Respiratory acidosis is not the correct answer. Respiratory acidosis is a condition where the blood pH is low (below 7.35) due to high carbon dioxide levels (above 45 mmHg) caused by hypoventilation. The client's blood pH is low (7.2) but the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory acidosis.
Choice D reason: This is the correct answer. Metabolic acidosis is a condition where the blood pH is low (below 7.35) due to low bicarbonate levels (below 22 mEq/L) caused by excessive production or intake of acids or loss of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which indicates metabolic acidosis.
Correct Answer is D
Explanation
Choice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.
Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.
Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.
Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.
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