A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
"I will wait 15 minutes after drinking coffee to measure my blood pressure."
"I will measure my blood pressure while my arm is elevated above my heart."
"I should remove constrictive clothing prior to measuring my blood pressure."
"I should measure my blood pressure immediately after eating breakfast.”
The Correct Answer is C
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Ego integrity vs. despair.
Choice A rationale:
Erikson's Theory of Psychosocial Development outlines various stages of development that individuals go through across their lifespan. In the final stage, which occurs in late adulthood, individuals either experience a sense of ego integrity or despair. Ego integrity is characterized by a sense of fulfillment and satisfaction with one's life choices, while despair is marked by feelings of regret and a sense of unfulfillment. The older adult client expressing that their life has no purpose suggests a struggle with finding meaning and satisfaction, aligning with the ego integrity vs. despair stage.
Choice B rationale:
Generativity vs. self-absorption is a stage that occurs during middle adulthood. It involves concerns about contributing to society and the next generation. This stage is not applicable to the scenario described with an older adult who is grappling with a lack of purpose in life.
Choice C rationale:
Identity vs. role confusion is a stage that occurs during adolescence, where individuals explore their sense of self and develop their identities. This stage is not relevant to the older adult client's situation of feeling purposeless.
Choice D rationale:
Intimacy vs. isolation is a stage that typically occurs during young adulthood, where individuals seek close and meaningful relationships with others. This stage is not appropriate for the older adult's feelings of lacking purpose.
Correct Answer is B
Explanation
The correct answer is choice B: "Support the client's feet with foot boots."
Choice A rationale:
Flexing the client's feet using pillows might not be sufficient to prevent foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, and using pillows alone may not provide adequate support to prevent this condition.
Choice B rationale:
Supporting the client's feet with foot boots is the most appropriate intervention to prevent foot drop due to immobility. Foot boots are specifically designed to hold the foot in a dorsiflexed position, preventing the calf muscles from tightening and causing foot drop.
Choice C rationale:
Placing a hand roll under the client's heels might offer some relief, but it's not the most effective intervention for preventing foot drop. Hand rolls are generally used to prevent footdrop by keeping the ankles in a neutral position, rather than solely supporting the heels.
Choice D rationale:
Removing ankle-foot orthotic devices at bedtime is not recommended if the client is at risk for developing foot drop. Ankle-foot orthotic devices are designed to provide continuous support to the feet and prevent muscle contractures. Removing them at bedtime could compromise the effectiveness of the intervention.
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