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 A
Explanation
Choice A reason: Constipation is the nurse's priority for preventive care, as it is a common and serious side effect of morphine and other opioids, which can slow down the bowel movements and cause hard, dry stools. The nurse would advise the older adult to increase their fiber and fluid intake, use stool softeners or laxatives as prescribed, and report any signs of bowel obstruction, such as abdominal pain, bloating, nausea, or vomiting.
Choice B reason: Poor liquid intake is not the nurse's priority for preventive care, as it is not directly related to the use of morphine, although it can contribute to constipation and dehydration. The nurse would advise the older adult to drink enough fluids, unless they have a fluid restriction, and to monitor their urine output, color, and specific gravity.
Choice C reason: Diarrhea is not the nurse's priority for preventive care, as it is not a common side effect of morphine, although it can occur in some cases due to an allergic reaction, intolerance, or overdose. The nurse would advise the older adult to report any episodes of diarrhea, as it can cause dehydration, electrolyte imbalance, or malabsorption.
Choice D reason: Poor solid food intake is not the nurse's priority for preventive care, as it is not directly related to the use of morphine, although it can affect the nutritional status and wound healing of the older adult. The nurse would advise the older adult to eat a balanced diet that meets their caloric and protein needs, and to avoid foods that can cause gas, indigestion, or constipation.
Correct Answer is C
Explanation
Choice A reason: A nasogastric tube may be necessary for some patients with dysphagia, which is difficulty swallowing, but not for dysarthria, which is difficulty speaking.
Choice B reason: Stems from severe rheumatoid arthritis is false because dysarthria is caused by damage to the nerves or muscles that control speech, not by inflammation of the joints.
Choice C reason: Physical therapy can be beneficial is true because dysarthria can be improved by exercises that strengthen the speech muscles and improve coordination.
Choice D reason: Can affect the balance is false because dysarthria does not affect the vestibular system, which is responsible for balance and spatial orientation.
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