How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A 45-year-old mother of 3 young children is at the doctor's office and her blood pressure is 152/92. This is the first time that has ever shown an elevated reading. She is concerned that she has hypertension. The nurse's best response would be:

A.

"Fortunately, hypertension isn't related to other diseases and is easily treated"

B.

"A single reading may not mean anything. We will take it again, 2 more times, within the next few weeks."

C.

"It looks like you have high blood pressure now. We'll check it again in 3 months"

D.

"You may have hypertension, but there is little else that can be done except medication."

Answer and Explanation

The Correct Answer is B

A. "Fortunately, hypertension isn’t related to other diseases and is easily treated":
 This is misleading-hypertension is related to many other diseases (e.g., cardiovascular, renal).

B. "A single reading may not mean anything. We will take it again, 2 more times, within the next few weeks.":
 Hypertension diagnosis requires two or more elevated readings on separate occasions. One elevated BP does not confirm diagnosis.

C. "It looks like you have high blood pressure now. We'll check it again in 3 months":
 Waiting 3 months may delay early detection. BP should be rechecked within a few weeks to confirm or rule out hypertension.

D. "You may have hypertension, but there is little else that can be done except medication":
 Hypertension can often be managed with lifestyle changes in addition to or instead of medication, especially initially.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A. Use a cuff of the appropriate size for the client:
Using a cuff that is too small or too large can cause inaccurate readings. Proper sizing is crucial.

B. Assist the client to the bathroom to void:
While a full bladder can slightly affect BP, this is not the most essential step to ensure an accurate reading.

C. Apply the cuff loosely around the client’s arm:
A loose cuff will cause an inaccurate (falsely high) reading.

D. Obtain the reading in the early morning:
While BP naturally varies, the time of day is not critical to accurate technique unless part of a specific assessment schedule.

Correct Answer is B

Explanation

A. Clean the skin and perineum with hot water after each episode of incontinence:
Hot water can damage the skin and strip protective oils, increasing breakdown risk.

B. Apply a moisture barrier ointment to the skin:
Barrier creams protect the skin from moisture and irritants, preventing skin breakdown.

C. Check the client’s skin every 8 hr for signs of breakdown:
Skin should be assessed more frequently (e.g., every 2–4 hours) in clients with incontinence.

D. Request a prescription for an indwelling catheter:
Indwelling catheters are associated with infection risk and are not recommended solely for incontinence unless absolutely necessary.

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

Register