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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because using smooth muscle relaxants is not the most important aspect of care for the nurse to maintain when assisting an older client with urinary incontinence. Smooth muscle relaxants are medications that can relax the bladder and reduce the urge to urinate, but they can also cause side effects such as dry mouth, constipation, or blurred vision. They are not suitable for all types of urinary incontinence, and they should be used with caution and under medical supervision.
Choice B reason: This is incorrect because availability of protective rubber garments is not the most important aspect of care for the nurse to maintain when assisting an older client with urinary incontinence. Protective rubber garments are devices that can prevent urine leakage and protect the skin and clothing, but they can also cause skin irritation, infection, or odor. They are not a cure for urinary incontinence, and they should be used as a last resort or in combination with other interventions.
Choice C reason: This is incorrect because using indwelling urinary catheters is not the most important aspect of care for the nurse to maintain when assisting an older client with urinary incontinence. Indwelling urinary catheters are tubes that can drain urine from the bladder and collect it in a bag, but they can also cause complications such as urinary tract infections, bladder spasms, or trauma. They are not recommended for long-term use, and they should be used only when other methods have failed or are contraindicated.
Choice D reason: This is correct because maintaining an attitude that is respectful and positive about resolving the problem is the most important aspect of care for the nurse to maintain when assisting an older client with urinary incontinence. Urinary incontinence can cause embarrassment, shame, isolation, or depression in older clients, and they may be reluctant to seek help or comply with treatment. The nurse should respect the client's dignity, privacy, and preferences, and provide education, support, and encouragement. The nurse should also assess the underlying causes and contributing factors of urinary incontinence, and implement individualized and evidence-based interventions.
Correct Answer is C
Explanation
Choice A reason: A licensed practical nurse is qualified to care for the feet of a client with diabetes is false because foot care for people with diabetes requires specialized training and skills that are beyond the scope of practice of a licensed practical nurse. A registered nurse or a podiatrist should provide foot care for people with diabetes, as they can assess, treat, and prevent foot problems such as ulcers, infections, or nerve damage.
Choice B reason: Onychomycosis is quickly eradicated with antifungal creams or powders is false because onychomycosis, or fungal nail infection, is a stubborn and persistent condition that can take months or years to clear. Antifungal creams or powders are usually not effective for onychomycosis, as they cannot penetrate the nail plate. Oral antifungal medication or laser therapy may be needed to treat onychomycosis.
Choice C reason: Maintaining oral hydration may reduce the incidence of xerosis is true because xerosis, or dry skin, is a common problem for older adults, as their skin produces less oil and moisture. Drinking enough fluids can help hydrate the skin and prevent dryness, itching, cracking, or infection. The recommended fluid intake for older adults is 2400 mL/day, according to the National Council on Aging.
Choice D reason: Ram’s-horn nail should be cut to give a smooth, rounded edge is false because ram’s-horn nail, or onychogryphosis, is a condition where the nail becomes thickened, curved, and distorted. Cutting the nail can be difficult and painful, and may cause bleeding or infection. A podiatrist should trim and file the nail, and treat any underlying causes of the condition.
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