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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.

A. Straighten the auditory canal by pulling it down and toward the front. B. Gently pull the auricle up and back before instilling the drops. C. Ask the client to lower the head and take a deep breath during the instillation. D. Don sterile glove and gently insert one finger in the canal to promote the flow of the drops.

Correct Answer is B

Explanation

Gently pull the auricle up and back before instilling the drops. This technique straightens the auditory canal and allows the drops to reach the eardrum.

It also prevents contamination of the ear canal by the finger.

Choice A is wrong because pulling the auditory canal down and toward the front is the proper method for children, not adults.

This technique is used for children because their auditory canal is shorter and more curved than adults.

Choice C is wrong because lowering the head and taking a deep breath during the instillation has no effect on the administration of otic drops.

It may also cause discomfort or dizziness for the client.

Choice D is wrong because wearing sterile gloves and inserting one finger in the canal is unnecessary and potentially harmful.

It may introduce bacteria or damage the ear canal or eardrum.

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A nurse is screening a community group for hypertension. Which person should be referred for immediate treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse evaluates the client hydration status, using what assessment techniques? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

Which technique is the proper method to administer otic drops to an adult client?

Correct Answer is B

Explanation

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