A nurse is caring for a patient with a blood pressure reading of 148/92 mmHg. What classification of blood pressure is this reading?
Normal.
Stage 1 hypertension.
Stage 2 hypertension.
Elevated.
The Correct Answer is C
Choice A reason: Normal blood pressure is <120/<80 mmHg, far below 148/92 mmHg, which is stage 2 hypertension per AHA guidelines. Assuming normal misclassifies the reading, risking untreated hypertension, leading to complications like stroke or heart failure. Accurate classification ensures proper management with lifestyle changes or medications.
Choice B reason: Stage 1 hypertension is 130-139/80-89 mmHg, lower than 148/92 mmHg, which is stage 2. Misclassifying as stage 1 underestimates severity, potentially delaying aggressive treatment like dual antihypertensives. Correct staging ensures timely intervention, critical for preventing cardiovascular damage in patients with elevated blood pressure readings.
Choice C reason: Stage 2 hypertension, per AHA, is ≥140/≥90 mmHg, matching 148/92 mmHg. This requires immediate lifestyle changes and likely medications to prevent cardiovascular events. Accurate classification guides treatment, ensuring blood pressure control, reducing risks of stroke, heart attack, or kidney damage in patients with significant hypertension.
Choice D reason: Elevated blood pressure is 120-129/<80 mmHg, below 148/92 mmHg, which is stage 2 hypertension. Assuming elevated underestimates the condition, risking inadequate intervention and progression to organ damage. Correct classification ensures appropriate management, critical for controlling hypertension and preventing long-term complications in affected patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Full range of motion against gravity only corresponds to a 3/5 muscle strength rating, indicating the muscle can move the joint against gravity but not additional resistance. This is weaker than 4/5, which includes some resistance, making this choice incorrect for the described strength level.
Choice B reason: Visible muscle contraction without joint movement indicates a 1/5 rating, reflecting minimal strength, often seen in severe neurological or muscular disorders. This is far below a 4/5 rating, which requires full range of motion and resistance, making this choice irrelevant to the question.
Choice C reason: A 4/5 muscle strength rating indicates full range of motion against gravity with some resistance, but not maximal. This reflects good muscle function, slightly below normal, often due to minor injury or fatigue. It aligns with standard muscle strength scales, making it the correct choice.
Choice D reason: Full range of motion against gravity with full resistance corresponds to a 5/5 rating, indicating normal muscle strength. This is stronger than 4/5, which involves only some resistance, reflecting a slight deficit. This choice does not match the described strength level.
Correct Answer is A
Explanation
Choice A reason: Abdominal distention is an unexpected finding, potentially indicating serious issues like bowel obstruction, ascites, or organ enlargement, requiring urgent reporting. Unlike normal findings like symmetry, distention demands investigation. Prompt documentation ensures timely diagnosis and intervention, critical for preventing complications in patients with abdominal abnormalities.
Choice B reason: Silver striae are expected from skin stretching (e.g., pregnancy or weight gain), not typically concerning unless new or severe. Distention is more urgent. Assuming striae require reporting risks diverting focus from serious findings, potentially delaying evaluation of critical abdominal conditions needing immediate medical attention.
Choice C reason: Borborygmus (bowel sounds) is a normal finding, indicating active digestion, unless absent or hyperactive. Distention is abnormal and urgent. Assuming borborygmus requires reporting risks misprioritizing normal findings, neglecting serious issues like distention, critical for timely diagnosis and management of abdominal pathology.
Choice D reason: Abdominal symmetry is expected in healthy assessments, unlike distention, which signals pathology. Assuming symmetry is unexpected risks overlooking abnormal findings, diverting focus from urgent issues like obstruction or ascites. Reporting distention ensures prompt evaluation, critical for addressing underlying causes and preventing complications in patients.
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.