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 D
Explanation
The hypothalamus is the primary center for thermoregulation. When a client sustains a head injury, especially involving the hypothalamus or brainstem, the body may lose its ability to properly regulate temperature. This can lead to a neurogenic fever, which is a non-infectious fever caused by damage to the thermoregulatory center.
Rationale for correct answer:
D. Ineffective thermoregulation: This nursing diagnosis reflects an actual disruption in temperature regulation due to neurological impairment. It encompasses both fever and hypothermia, making it the most comprehensive and accurate for this client.
Rationale for incorrect answers:
A. Risk for imbalanced body temperature: This diagnosis is used when the risk factors are present, but the condition has not yet occurred.
B. Hyperthermia refers to an elevated body temperature due to external heat or failure of heat loss mechanisms (e.g., heatstroke, environmental exposure).
C. Hypothermia is defined as a core body temperature below 35°C (95°F). There’s no indication that the client is hypothermic, and with the mention of neurogenic fever, the temperature is expected to increase, not decrease.
Take-home points:
- Ineffective thermoregulation is the most appropriate nursing diagnosis for clients with neurologically driven temperature abnormalities, such as neurogenic fever.
- Nurses must differentiate between external causes of hyperthermia and central (neurogenic) causes, especially in clients with head injuries.
Correct Answer is B
Explanation
Accurate blood pressure (BP) measurement is a fundamental nursing skill. If the cuff is deflated too quickly, the nurse may miss the first Korotkoff sound (systolic BP) or inaccurately estimate diastolic pressure. Deflating the cuff too slowly can cause venous congestion, discomfort, and a falsely high diastolic reading. Best practice guidelines recommend a cuff deflation rate of 2–3 mmHg per second to ensure an accurate reading without patient discomfort.
Rationale for correct answer:
B. 30–45 seconds: This is the recommended time frame for releasing the cuff when using a 2–3 mmHg/second deflation rate, which allows clear identification of both systolic and diastolic sounds.
Rationale for incorrect answers:
A. 10–20 seconds: Deflating the cuff this quickly equates to a deflation rate that is too fast (greater than 5 mmHg per second). This may result in missing Korotkoff sounds and underestimating the true BP values, especially systolic pressure.
C. 1 -- A.5 minutes: Deflating the cuff this slowly would equate to less than 1 mmHg per second, which is unnecessarily prolonged. It can cause venous congestion, discomfort, and may lead to a falsely elevated diastolic pressure.
D. 3–C.5 minutes: This is excessively slow and not clinically appropriate.
Take-home points:
- The blood pressure cuff should be deflated at a rate of 2-3 mmHg per second, resulting in a total release time of approximately 30-45 seconds, depending on the pressure range.
- Incorrect deflation rates (too fast or too slow) can lead to inaccurate readings and impact clinical decisions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.