Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-year-old patient with newly diagnosed hypertension?
128/76 mm Hg
148/78 mm Hg
98/56 mm Hg
128/92 mm Hg
The Correct Answer is A
Choice A reason: A blood pressure of 128/76 mm Hg is within the target range for a patient with hypertension, indicating that the current therapy is effectively managing the condition. This reading is below the generally accepted threshold for hypertension, which is 140/90 mm Hg.
Choice B reason: A blood pressure of 148/78 mm Hg is above the target range for hypertension management. This reading suggests that the patient may need an adjustment in their therapy to better control their blood pressure and reduce the risk of cardiovascular complications.
Choice C reason: A blood pressure of 98/56 mm Hg is too low and may indicate hypotension, which can be a concern, especially if the patient experiences symptoms like dizziness or fainting. This reading suggests that the patient's therapy may need to be adjusted to avoid excessively lowering blood pressure.
Choice D reason: A blood pressure of 128/92 mm Hg shows an elevated diastolic pressure, which is above the target range. This indicates that the patient's hypertension is not fully controlled, and adjustments in therapy may be needed to bring both systolic and diastolic pressures within the desired range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.
Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.
Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.
Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.
Correct Answer is D
Explanation
Choice A reason: Liver cirrhosis is characterized by chronic liver damage leading to scarring and liver failure. The typical lab findings for liver cirrhosis would include elevated liver enzymes (ALT, AST), bilirubin, and low albumin levels, which are not mentioned in the given test results.
Choice B reason: Acute hepatitis refers to the inflammation of the liver, usually caused by viral infections or toxins. Lab results consistent with acute hepatitis would show elevated liver enzymes (ALT, AST) significantly higher than normal, which are not provided in the text.
Choice C reason: Cholecystitis is the inflammation of the gallbladder, often due to gallstones. Lab findings for cholecystitis may include elevated white blood cell count and sometimes mild elevation of liver enzymes, but not the specific elevated levels of serum amylase and lipase.
Choice D reason: Acute pancreatitis is an inflammation of the pancreas, and the hallmark lab findings include significantly elevated serum amylase and lipase levels. The test results show serum amylase of 920 units/L (reference: 30-220 units/L) and serum lipase of 704 units/L (reference: 0-160 units/L), which are highly indicative of acute pancreatitis. Elevated serum glucose and low serum calcium levels are also consistent with this diagnosis.
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