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 A
Explanation
Step 1 is: Convert 1 liter to milliliters 1 L = 1000 mL
Step 2 is: Convert 6 hours to minutes 6 × 60 = 360 min
Step 3 is: Calculate drops per minute using tubing drop factor (1000 mL ÷ 360 min) × 15 gtt/mL = (2.77 mL/min) × 15 = 41.66 drops/min
Step 4 is: Round to the nearest whole number Final answer: 42 drops per minute
Correct Answer is B
Explanation
What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.
Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.
Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.
Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.
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