A 56-year-old male client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response?
"Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination."
"We will need to reevaluate your blood pressure because age places you at high risk for hypertension."
"A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.
"You have no need to worry. Your pressure is probably elevated because you are being tested."
The Correct Answer is C
A. "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination.": This response is premature as it assumes a diagnosis of hypertension based on a single elevated blood pressure reading without further assessment or confirmation.
B. "We will need to reevaluate your blood pressure because age places you at high risk for hypertension.": While age is a risk factor for hypertension, it is important not to jump to conclusions based on one blood pressure reading. Reevaluation and monitoring are necessary before making any definitive diagnoses or treatment decisions.
C. "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.": This response is appropriate because it acknowledges the need for further assessment and monitoring before determining if the client has hypertension. It also educates the client about the importance of multiple readings for an accurate diagnosis.
D. "You have no need to worry. Your pressure is probably elevated because you are being tested.": This response dismisses the client's concerns and does not provide accurate information about blood pressure assessment and hypertension diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.
B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.
C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.
D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Numbness in extremities: Numbness in extremities is not a common adverse effect of digoxin. The focus of digoxin monitoring is primarily on cardiovascular and gastrointestinal effects.
B. Fatigue: Fatigue is a common adverse effect of digoxin and can indicate toxicity or overdose. Clients taking digoxin should be monitored for increased fatigue or weakness.
C. Shortness of breath: Shortness of breath can occur as an adverse effect of digoxin toxicity, particularly if it leads to pulmonary congestion or heart failure exacerbation.
D. Anorexia: Anorexia, or loss of appetite, can be a gastrointestinal adverse effect of digoxin. Clients may experience nausea, vomiting, or anorexia, which can contribute to weight loss and electrolyte imbalances.
E. Chest pain: Chest pain can be a sign of digoxin toxicity, especially if it is associated with other symptoms such as shortness of breath or palpitations. It is essential to evaluate any chest pain in a client taking digoxin.
F. Confusion: Confusion or changes in mental status can occur with digoxin toxicity, particularly in older adults. Clients should be monitored for signs of confusion, delirium, or other cognitive changes.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
