A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/74 mm Hg places him in which of the following categories or stages?

Hypertension stage 2

Elevated or Prehypertension

Hypertension stage 1

Within the expected reference range

Answer and Explanation

The Correct Answer is B

A. Hypertension stage 2: Hypertension stage 2 is defined as a systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg. The client’s reading of 124/74 mm Hg does not fall into this category.

B. Elevated or Prehypertension: A systolic blood pressure between 120-129 mm Hg and a diastolic <80 mm Hg is classified as elevated or prehypertension. The client’s systolic BP of 124 mm Hg places him in this category.

C. Hypertension stage 1: Hypertension stage 1 is defined as a systolic BP between 130-139 mm Hg or diastolic BP between 80-89 mm Hg. The client’s BP of 124/74 mm Hg does not meet this criterion.

D. Within the expected reference range: The normal range for blood pressure is less than 120/80 mm Hg. The client’s BP of 124/74 mm Hg is slightly elevated and does not fall within the expected reference range.

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Correct Answer is A

Explanation

A. Check pedal pulses every 15 min. Checking pedal pulses every 15 minutes is essential to monitor for adequate blood flow to the extremity and to detect any signs of arterial obstruction or complications at the catheter insertion site.

B. Keep the client in high-Fowler's position for 6 hr. The client should remain flat or in a low-Fowler's position to reduce the risk of bleeding at the femoral artery access site. High-Fowler's position is contraindicated.

C. Remind the client not to turn from side to side. Clients may be allowed to turn gently, but they should avoid putting pressure on the insertion site. Complete immobility is unnecessary.

D. Perform passive range-of-motion for the affected extremity. Passive range of motion is not appropriate in the immediate post-procedure period, as the extremity should remain still to prevent bleeding.

A. Valve disorder B. Asthma C. Pulmonary embolism D. Heart failure

Correct Answer is D

Explanation

A. Valve disorder: While valve disorders can cause fatigue and dyspnea, the client’s history of hypertension, tachycardia, hypercholesteremia, and medication noncompliance are more suggestive of heart failure rather than a valve disorder.

B. Asthma: Asthma typically presents with wheezing, shortness of breath, and chest tightness. It is less likely to be the cause of symptoms in this scenario, where cardiac conditions and medication noncompliance are noted.

C. Pulmonary embolism: While pulmonary embolism can cause dyspnea and tachycardia, the client's chronic cardiovascular history and edema are more consistent with heart failure than an acute pulmonary embolism.

D. Heart failure: The client has a history of hypertension, tachycardia, and hypercholesteremia, along with medication noncompliance, tachycardia, and edema. These are classic signs of heart failure, making this the most likely diagnosis

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A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/74 mm Hg places him in which of the following categories or stages?

Nursing Test Bank

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Correct Answer is A

Explanation

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Explanation

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A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/74 mm Hg places him in which of the following categories or stages?