A nurse is screening a community group for hypertension. Which person should be referred for immediate treatment?
A 20-year-old client who has a blood pressure of 125/60 mm Hg.
A 40-year-old client who has a blood pressure of 138/98 mm Hg.
A 55-year-old client who has a blood pressure of 142/68 mm Hg.
A 70-year-old client who has a blood pressure of 150/78 mm Hg.
The Correct Answer is B
A 40-year-old client who has a blood pressure of 138/98 mm Hg should be referred for immediate treatment. This is because this client has grade 1 hypertension according to the International Society of Hypertension (ISH) guidelines, which define hypertension as a systolic blood pressure (SBP) of 140 mm Hg or higher and/or a diastolic blood pressure (DBP) of 90 mm Hg or higher in the office or clinic. This client also has a high risk of cardiovascular complications due to their age and elevated DBP.
Choice A is wrong because a 20-year-old client who has a blood pressure of 125/60 mm Hg does not have hypertension. This client has normal blood pressure according to the ISH guidelines, which define normal blood pressure as an SBP of less than 130 mm Hg and a DBP of less than 85 mm Hg in the office or clinic. This client also has a low risk of cardiovascular complications due to their age and low DBP.
Choice C is wrong because a 55-year-old client who has a blood pressure of 142/68 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend lifestyle interventions for three to six months before medication in patients with grade 1 hypertension and no comorbidities.
This client may have other risk factors that need to be assessed, such as obesity, diabetes, or smoking, but they do not require urgent referral.
Choice D is wrong because a 70-year-old client who has a blood pressure of 150/78 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend a target blood pressure of less than 140/90 mm Hg within three months for patients older than 65 years, and after three months reduce the target to less than 130/80 mm Hg.
This client may have other risk factors that need to be assessed, such as chronic kidney disease, heart failure, or atrial fibrillation, but they do not require urgent referral.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because helping the client to recognize and avoid situations that cause anxiety can reduce the frequency and severity of acute anxiety episodes. According to , a nurse should encourage the client to verbalize feelings and provide a calm and supportive environment.
Choice A is wrong because isolating the client when there are observable physiologic symptoms of anxiety can increase the client’s sense of fear and loneliness.
The nurse should stay with the client and offer reassurance and comfort.
Choice B is wrong because ignoring the client’s behavior as obvious attempts to gain attention can make the client feel rejected and misunderstood.
The nurse should acknowledge the client’s feelings and provide empathy and support.
Choice C is wrong because reducing all stress whenever the client seems anxious can prevent the client from learning coping skills and developing resilience.
The nurse should help the client to identify healthy ways of managing stress and anxiety.
Correct Answer is C
Explanation
This is because renal calculi can cause renal colic, which is a sudden and intense pain in the flank area that radiates to the groin or testicles.
The pain is caused by the stone obstructing the ureter and triggering spasms.
Choice A is wrong because a feeling of pressure in the bladder is more likely to indicate a lower urinary tract infection or an overactive bladder.
Choice B is wrong because a mild, burning pain when urinating is more likely to indicate a urinary tract infection or a urethral injury.
Choice D is wrong because a constant, dull, aching pain in the right upper quadrant is more likely to indicate a liver or gallbladder problem.
Normal ranges for urine pH are 4.5 to 8.0, and for specific gravity are 1.005 to 1.030.
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