When evaluating a community’s health promotion needs, what is the first step the nurse should take?

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.

Answer and explanation The correct answer is B. Choice A rationale

Having the 16-month-old child play in another room during breastfeeding might not be feasible or safe, depending on the child’s maturity and the safety of the environment.

Choice B rationale

Reading a book to the 16-month-old child while the mother is breastfeeding the infant can be a practical solution. It allows the mother to attend to both children simultaneously, keeping the older child engaged while tending to the infant.

Choice C rationale

While watching TV might keep the toddler occupied, it’s not the best option. Excessive screen time is not recommended for children at this age.

Choice D rationale

Giving the toddler crayons and paper is a good idea, but it might not keep the child engaged for the entire duration of the breastfeeding.