A nurse is caring for a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110mm Hg. Which of the following actions should the nurse take first?

Report the blood pressure reading to the charge nurse.

Administer an antihypertensive medication.

Remeasure the client's blood pressure.

Instruct the client to remain in bed.

Answer and Explanation

The Correct Answer is C

A. Report the blood pressure reading to the charge nurse: While notifying the charge nurse is important, the nurse should first validate the high reading by rechecking the blood pressure. Acting on a single, unverified reading could lead to unnecessary interventions or missed opportunities for accurate assessment.

B. Administer an antihypertensive medication: Administering antihypertensive medication based solely on a report without rechecking the blood pressure could be unsafe. Verification ensures that treatment is based on accurate clinical data and prevents unnecessary medication administration.

C. Remeasure the client's blood pressure: The first action should always be to recheck an unusually high or abnormal vital sign reading to confirm its accuracy. Errors can occur during measurement, and accurate confirmation is critical before proceeding with further interventions in a client with chronic kidney failure.

D. Instruct the client to remain in bed: While keeping the client in bed can help prevent complications if severe hypertension is confirmed, it is not the priority action. Verifying the blood pressure reading must occur first to determine the appropriate course of action.

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Correct Answer is C

Explanation

A. "You will also find he will want to wear girls' clothes, including dresses, as well.": This response incorrectly assumes that playing with dolls predicts future behavior regarding gender expression, which is not accurate. It also may cause unnecessary worry for the parent.

B. "Gender identity is generally not established until the child is around five years old.": While partially true, this response does not directly address the parent's concern about the current behavior. It misses the opportunity to explain that imitating caregiving is a normal developmental stage.

C. "At two years of age, toddlers often engage in play that imitates adult actions.": This response correctly explains that toddlers naturally mimic the behavior they observe in adults, including caregiving activities, without it indicating future gender identity. Play is a normal part of development at this age.

D. "When a male toddler chooses to play with dolls, it is an indication he will later identify as a female.": This statement is inaccurate and misleading. A toddler’s choice of toys reflects curiosity and imitation, not a prediction of future gender identity or roles.

A. “I may notice an increase in the firmness of my breasts.” B. "My estrogen levels will elevate” C. "I may experience more vaginal dryness." D. "I may become cold more often."

Correct Answer is C

Explanation

A. “I may notice an increase in the firmness of my breasts.”: During menopause, breasts typically become less firm and more fatty due to decreased estrogen levels. Loss of glandular tissue and changes in connective tissue elasticity cause breasts to feel softer, not firmer.

B. "My estrogen levels will elevate”: Estrogen levels decline significantly during menopause, not elevate. This hormonal decrease leads to many of the physical and emotional symptoms associated with menopause, including hot flashes, vaginal dryness, and bone density loss.

C. "I may experience more vaginal dryness.": Vaginal dryness is a common and expected symptom during menopause due to the reduction in estrogen. Lower estrogen levels cause thinning and decreased lubrication of the vaginal tissues, often resulting in discomfort during intercourse and increased risk of irritation or infection.

D. "I may become cold more often.": Clients undergoing menopause typically experience hot flashes and night sweats, not an increased tendency to feel cold. Hot flashes are sudden sensations of heat and are one of the most recognized and frequent symptoms of menopausal transition.

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A nurse is caring for a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110mm Hg. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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