A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse?
Measure the blood pressure in sitting and standing positions.
Measure the blood pressure in the left arm.
Document the findings in the medical record; elevated blood pressures are normal in older adults.
Immediately contact the medical provider.
None of the above.
The Correct Answer is B
Choice A reason: Measure the blood pressure in sitting and standing positions is not the next action by the nurse, as it is not relevant to the situation. The nurse should compare the blood pressure readings from both arms, not from different postures.
Choice B reason: Measure the blood pressure in the left arm is the next action by the nurse, as it can help determine if the high blood pressure is consistent or isolated to one arm. A difference of more than 10 mm Hg between the arms may indicate a vascular problem, such as atherosclerosis, aneurysm, or coarctation of the aorta.
Choice C reason: Document the findings in the medical record; elevated blood pressures are normal in older adults is not the next action by the nurse, as it is inaccurate and irresponsible. The nurse should not assume that elevated blood pressures are normal in older adults, as they may indicate hypertension, which is a risk factor for cardiovascular disease, stroke, and kidney damage. The nurse should also not document the findings without further assessment and intervention.
Choice D reason: Immediately contact the medical provider is not the next action by the nurse, as it may be premature and unnecessary. The nurse should first confirm the accuracy of the blood pressure readings by measuring the blood pressure in the left arm and checking the calibration of the device. The nurse should also consider other factors that may affect the blood pressure, such as pain, stress, caffeine, or medication.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the next action by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Drinking large amounts of alcohol can relieve symptoms of essential tremor is false because essential tremor is a different neurological disorder from PD, and alcohol can worsen PD symptoms or interact with medications.
Choice B reason: Motor tremors and slow movement accompany severe cognitive impairment is false because not all people with PD develop cognitive impairment, and the severity of motor and cognitive symptoms may not correlate.
Choice C reason: It is advised to take levodopa-carbidopa on an empty stomach is true because food, especially protein, can interfere with the absorption of levodopa-carbidopa, which is the main medication for PD.
Choice D reason: Lewy body dementia (LBD) is the most common form of dementia is false because Alzheimer's disease is the most common form of dementia, and LBD is a related but distinct condition that can affect some people with PD.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Physical status is an important assessment for post-fall prevention, as it can identify the possible causes and consequences of the fall, such as injuries, pain, mobility, balance, strength, vision, hearing, cognition, and medication use. Physical status can also help determine the appropriate interventions and referrals for the older adult, such as physical therapy, occupational therapy, or home health care.
Choice B reason: Financial status is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, financial status may influence the older adult's access to health care, social support, and assistive devices, which may affect their recovery and quality of life. Financial status may also be a source of stress or anxiety for the older adult, which may impair their mental and emotional well-being.
Choice C reason: Occupational history is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, occupational history may provide some information about the older adult's past and current activities, skills, and interests, which may help tailor the interventions and goals for the older adult. Occupational history may also reflect the older adult's sense of identity, purpose, and satisfaction, which may affect their motivation and engagement.
Choice D reason: Environment is an important assessment for post-fall prevention, as it can identify the potential hazards and barriers that may contribute to the fall, such as poor lighting, slippery floors, clutter, loose rugs, stairs, or furniture. Environment can also help determine the appropriate modifications and adaptations that can reduce the risk of future falls, such as installing grab bars, handrails, ramps, or alarms. Environment can also influence the older adult's comfort, safety, and independence at home or in other settings.
Choice E reason: None of the above is not the correct answer, as there are two choices that are essential assessments for post-fall prevention.
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