A 56-year-old client has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, “My pressure has never been this high. Will the health care provider prescribe medication to reduce it?” What is the nurse’s best response?
We will need to reevaluate your blood pressure. This reading places you at high risk for hypertension.
You have no need to worry. Your pressure is fine; you are just being tested.
Yes, this is prevalent among males. It is fortunate we caught it during your routine examination.
An elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis is made.
The Correct Answer is D
Choice A reason: While this statement acknowledges the elevated reading, it prematurely implies a diagnosis and risk without confirming through repeated measurements. Hypertension diagnosis requires multiple readings over time.
Choice B reason: This response is dismissive and inaccurate. A reading of 146/96 mm Hg is considered stage 2 hypertension and warrants further evaluation, not reassurance without context.
Choice C reason: Although hypertension is common among males, this response lacks clinical relevance and does not address the client’s concern about treatment or diagnosis.
Choice D reason: This is the most accurate and evidence-based response. A single elevated reading does not confirm hypertension. Diagnosis requires multiple elevated readings on separate occasions, ideally under standardized conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Ultrasound is not a standard screening tool for prostate cancer and is typically used after abnormal findings from PSA or digital rectal exams.
Choice B reason: PSA testing is a primary method for early detection of prostate cancer, especially in men over 50 or those with risk factors.
Choice C reason: Testicular self-examinations are important for detecting testicular cancer, not prostate cancer.
Choice D reason: CBC, BUN, and creatinine are general lab tests and do not specifically screen for prostate cancer.
Correct Answer is C
Explanation
Choice A reason: Tea-colored urine may suggest old blood or hematuria but is not the expected finding immediately after continuous bladder irrigation. It may indicate inadequate flushing or clot retention.
Choice B reason: Amber urine is typical in healthy individuals without hematuria. After a prostatectomy with irrigation, urine should be lighter due to dilution and blood clearance.
Choice C reason: Light pink urine is expected 24 hours after continuous bladder irrigation. It reflects mild hematuria and effective irrigation, indicating that bleeding is controlled and the bladder is being adequately flushed.
Choice D reason: Red wine–colored urine suggests active bleeding and may require intervention. It is not a normal finding and could indicate clot formation or hemorrhage.
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