A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?
Follow-up measurements of blood pressure
Immediate treatment by a physician
Nothing, because the nurse considers this reading is due to anxiety
A change in dietary intake
The Correct Answer is A
According to guidelines like JNC 7 and ACC/AHA, consistent elevated readings over multiple visits are necessary to diagnose hypertension. Nurses play a vital role in recognizing abnormal readings, educating patients, and guiding appropriate follow-up to prevent long-term complications like stroke or heart disease.
Rationale for correct answer:
A. Follow-up measurements of blood pressure: A single elevated BP does not confirm a diagnosis of hypertension. The nurse should recommend rechecking BP on separate occasions, as per guidelines, to determine if the elevation is persistent.
Rationale for incorrect answers:
B. Immediate treatment by a physician: Immediate treatment is not warranted based on a single mildly elevated BP unless the patient is symptomatic or has evidence of organ damage.
C. Nothing, because the nurse considers this reading is due to anxiety: While anxiety (white-coat hypertension) may cause temporary elevation, it should not be assumed without confirmation.
D. A change in dietary intake: Dietary changes (e.g., low sodium, DASH diet) are important in preventing or managing hypertension. However, before prescribing lifestyle changes, the first step is to confirm whether BP is consistently elevated.
Take-home points:
- A single reading of 130/90 mm Hg should prompt follow-up measurements, not immediate diagnosis or treatment.
- Nurses should avoid assumptions and use evidence-based protocols to guide BP assessment and education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When nurses measure BP, they are not simply evaluating blood flow, but rather the pressure exerted by circulating blood on the walls of the arteries during the cardiac cycle.
Rationale for correct answer:
B. Force of blood against arterial walls: Blood pressure specifically refers to the force exerted by the blood on the walls of the arteries as the heart pumps. Systolic pressure is the peak force during ventricular contraction, while diastolic pressure is the residual force during relaxation.
Rationale for incorrect answers:
A. Flow of blood through the circulation: Blood pressure is related to blood flow but does not measure it directly.
C. Force of blood against venous walls: While venous pressure exists, it is much lower than arterial pressure and is not what is measured during routine BP assessment.
D. Flow of blood through the heart: This refers to cardiac output or blood volume, not pressure. Blood pressure reflects resistance and force in the arteries, not the amount of blood passing through the heart chambers.
Take-home points:
- Blood pressure is the force of blood against the arterial walls, not a direct measure of blood flow or heart volume.
- Accurate understanding of BP helps nurses assess for hypertension, hypotension, and perfusion status, and supports safe clinical decision-making.
Correct Answer is ["C","D","E"]
Explanation
In clients who have had a stroke, especially those with facial drooping, dysphagia (difficulty swallowing), or immobility, the nurse must choose a method of taking temperature that minimizes risk (e.g., aspiration or injury) and provides consistent, accurate readings.
Rationale for correct answer:
C. Axillary: Safe, noninvasive, and easy to perform even in clients with limited mobility. While it is less accurate than core sites, it’s a reasonable alternative when oral and rectal sites are contraindicated.
D. Tympanic: Quick, noninvasive, and reflects core temperature well. Not affected by oral or facial dysfunctions. Can be performed even when the client has limited cooperation.
E. Temporal artery: Noninvasive, fast, and generally well tolerated. Can be used in immobile or neurologically impaired clients without requiring cooperation.
Rationale for incorrect answers:
A. Oral: Oral temperature measurement requires the client to close their mouth tightly around the probe, which is compromised by facial drooping and dysphagia.
B. Rectal: While rectal temperature is accurate, it is invasive and can be uncomfortable, particularly in older or immobile clients.
Take-home points:
- Avoid oral and rectal routes in clients with neurologic deficits, swallowing issues, or limited mobility due to safety concerns.
- Axillary, tympanic, and temporal artery methods are safe, noninvasive, and appropriate for clients with stroke-related impairments.
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