A nurse is reviewing the chart of an adult client recently diagnosed with hypertension. Which of the following blood pressure readings is most consistent with this diagnosis?
110/70 mm Hg
118/78 mm Hg
146/92 mm Hg
124/84 mm Hg
The Correct Answer is C
Choice A reason: A reading of 110/70 mm Hg is considered a normal blood pressure for an adult. This indicates that both the systolic and diastolic pressures are within the optimal range for cardiovascular health, showing no evidence of the elevated arterial wall tension that characterizes a diagnosis of hypertension.
Choice B reason: A reading of 118/78 mm Hg is categorized as a normal blood pressure according to the most recent clinical guidelines. While it is on the higher end of the normal range, it does not meet the diagnostic threshold for elevated blood pressure or hypertension in a clinical setting.
Choice C reason: A reading of 146/92 mm Hg is consistent with Stage 2 Hypertension. According to current medical standards, Stage 2 Hypertension is defined as a systolic pressure ≥ 140 mm Hg or a diastolic pressure ≥ 90 mm Hg. This reading clearly exceeds those parameters, requiring clinical monitoring and intervention.
Choice D reason: A reading of 124/84 mm Hg would be classified as "Elevated" blood pressure (if systolic is 120 to 129) or Stage 1 Hypertension (if diastolic is 80 to 89). While higher than normal, 146/92 mm Hg is a more definitive representation of a established hypertensive diagnosis frequently seen in clinical charts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Labeling a religious garment as a "barrier" in documentation reflects a lack of cultural sensitivity and professional adaptability. Cultural practices should be integrated into the care plan, and the nurse should work collaboratively with the patient to find ways to complete the assessment respectfully.
Choice B reason: Demanding immediate removal of a religious item without explanation is culturally insensitive and can damage the therapeutic relationship. It ignores the patient's autonomy and the significance of the garment, potentially causing the patient to feel violated or disrespected during the clinical encounter.
Choice C reason: Cultural competence involves recognizing the importance of religious practices while ensuring clinical safety. By explaining why the head needs to be examined and asking permission, the nurse shows respect for the patient's beliefs and fosters a collaborative environment, allowing the patient to participate in their care.
Choice D reason: Removing a patient's clothing or religious items while they are resting or without their knowledge is a violation of their privacy and autonomy. This action can be perceived as an assault on the patient's dignity and completely undermines the principles of trust and informed consent.
Correct Answer is B
Explanation
Choice A reason: A stethoscope is an acoustic medical device used primarily for auscultation, or listening to the internal sounds of an animal or human body. It is specifically designed for heart, lung, and bowel sounds and lacks the magnification or light source necessary to visualize the ear canal.
Choice B reason: An otoscope is a specialized medical instrument used to look into the ears. It consists of a handle and a head that contains a light source and a low-power magnifying lens, which allows the nurse to inspect the external auditory canal and the tympanic membrane.
Choice C reason: A sphygmomanometer is a diagnostic tool used to measure blood pressure. It consists of an inflatable cuff, a measuring unit (the mercury manometer or aneroid gauge), and a mechanism for inflation. It has no application in the visual assessment of the internal ear structures.
Choice D reason: A reflex hammer, or percussion hammer, is a medical instrument used by practitioners to test deep tendon reflexes. This is an essential part of the neurological physical examination to assess the integrity of the sensory and motor pathways and is not used for ear exams.
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