A group of student nurses are practicing taking blood pressures. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, “My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?” Which of the following responses by the nursing instructor would be best?
“A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made.”
“We will need to reevaluate your blood pressure because your age places you at high risk for hypertension.”
“Hypertension is prevalent among men: it is fortunate we caught this during your routine examination.”
“You have no need to worry. Your pressure is probably elevated because you are being tested.”
The Correct Answer is A
A. "A single elevated blood pressure does not confirm hypertension. A diagnosis of hypertension requires two or more elevated readings taken by your physician before a diagnosis can be made."
This response emphasizes the need for multiple elevated readings for a diagnosis of hypertension. It educates the individual about the diagnostic criteria and encourages them to seek further evaluation from their physician.
B. "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension."
This response might be seen as implying that age alone is a significant factor in determining hypertension, which may not be accurate. While age is a risk factor, the emphasis should be on the need for multiple readings and a physician's evaluation rather than attributing it solely to age.
C. "Hypertension is prevalent among men: it is fortunate we caught this during your routine examination."
This response suggests that the elevated blood pressure is automatically assumed to be hypertension based on gender. It is important to avoid making assumptions and instead focus on the need for proper evaluation and multiple readings for a hypertension diagnosis.
D. "You have no need to worry. Your pressure is probably elevated because you are being tested."
This response dismisses the individual's concerns and attributes the elevated blood pressure solely to the testing situation. While stress or anxiety can influence blood pressure readings, it's essential to address the need for further evaluation and not completely disregard the possibility of hypertension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet.”
Explanation: This statement reflects an understanding of the association between smoking and reduced blood flow, particularly due to nicotine's vasoconstrictive effects.
B. “The older I get the higher my risk for peripheral arterial disease gets.”
Explanation: While age is a non-modifiable risk factor for PAD, it is not a statement indicating a change in behavior to address risk factors. It is correct information but doesn't involve a proactive approach to risk reduction.
C. “Since my family is from Italy, I have a higher risk of developing peripheral arterial disease.”
Explanation: Family history is a non-modifiable risk factor, and the statement correctly identifies this risk factor. However, it doesn't address modifiable factors or actions to reduce risk.
D. “I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels.”
Explanation: This statement demonstrates an understanding of a dietary modification to lower cholesterol levels, which is a positive step toward reducing a modifiable risk factor for PAD.
Correct Answer is D
Explanation
A. Visible clubbing of the fingers and toes
Clubbing is a condition characterized by changes in the shape and appearance of the fingers and toes. It involves enlargement of the fingertips and the nails becoming curved and rounded. Clubbing is not typically associated with peripheral arterial occlusive disease (PAD). It is more commonly seen in conditions such as chronic respiratory or cardiovascular diseases.
B. Unequal peripheral pulses between extremities
Unequal peripheral pulses can be indicative of vascular abnormalities. However, in PAD, the characteristic finding is diminished or absent pulses rather than unequal pulses between extremities. Other conditions, such as arterial embolism or thrombosis, may present with unequal pulses.
C. Reddened extremities with muscle atrophy
Reddened extremities and muscle atrophy are not typical findings in PAD. These symptoms are more characteristic of conditions associated with chronic inflammation or compromised venous circulation, such as chronic venous insufficiency or venous stasis.
D. Loss of hair on the distal extremities
Loss of hair on the distal extremities, particularly on the lower legs and feet, is a common finding in PAD. It results from reduced blood flow and oxygen supply to the hair follicles in the affected areas.

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