According to current guidelines, which of the following reflects a normal adult blood pressure reading?
90/80
95/60
180/60
120/80
The Correct Answer is D
Choice A reason: A blood pressure of 90/80 mmHg is below normal, indicating hypotension, especially with a low systolic value. Normal adult blood pressure, per guidelines, is around 120/80 mmHg. Low readings may suggest dehydration or cardiovascular issues, requiring evaluation, making this choice incorrect.
Choice B reason: A reading of 95/60 mmHg is hypotensive, with both systolic and diastolic values below normal ranges. Normal blood pressure is approximately 120/80 mmHg, per American Heart Association guidelines. Such low readings may indicate shock or autonomic dysfunction, rendering this choice incorrect.
Choice C reason: A blood pressure of 180/60 mmHg is abnormal, with elevated systolic pressure indicating hypertension and a low diastolic value suggesting possible aortic regurgitation. Normal blood pressure is 120/80 mmHg. This reading requires urgent assessment, making it an incorrect choice for normal adult values.
Choice D reason: A blood pressure of 120/80 mmHg is considered normal for adults, per current guidelines like those from the American Heart Association. It reflects balanced systolic and diastolic pressures, indicating healthy cardiovascular function without signs of hypertension or hypotension, making it the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Dysesthesia refers to abnormal sensations, often painful, like burning or aching, due to nerve damage. While related to sensory nerve dysfunction, it does not specifically describe the pins and needles sensation, which is better characterized by paresthesia, making this term less precise for the patient’s complaint.
Choice B reason: Paresthesia describes abnormal sensations like pins and needles, typically from nerve compression or irritation, as in carpal tunnel syndrome. It accurately captures the patient’s reported left-hand sensation, aligning with clinical terminology for documenting transient or chronic sensory nerve disturbances, making it the appropriate term.
Choice C reason: Proprioception is the sense of body position, mediated by sensory receptors in muscles and joints, not related to pins and needles sensations. It involves spatial awareness, not cutaneous sensory abnormalities, so this term is irrelevant to the patient’s sensory complaint in the left hand.
Choice D reason: A sprain is a ligament injury, causing pain and swelling, not sensory disturbances like pins and needles. It is a musculoskeletal issue, unrelated to neurological symptoms of nerve irritation, making this term inappropriate for documenting the patient’s sensory nerve-related complaint.
Correct Answer is A
Explanation
Choice A reason: Assessment in the nursing process involves collecting subjective and objective data via interviews, physical exams, and observations to inform clinical judgments. This foundational step identifies patient needs, guiding subsequent planning. Accurate data collection ensures comprehensive care, preventing oversight of critical health issues and supporting effective diagnosis and intervention in clinical practice.
Choice B reason: Using problem-solving to prioritize outcomes and develop interventions describes the planning step, not assessment. Assessment focuses on data collection, not goal-setting. Assuming this misaligns with the nursing process, risking premature intervention without thorough data, which could lead to ineffective care plans or missed health issues in patient management.
Choice C reason: Assessing goal effectiveness and adjusting interventions pertains to the evaluation step, not assessment. Assessment gathers data to identify needs, not evaluate outcomes. Misidentifying this risks skipping data collection, leading to incomplete assessments and inappropriate interventions, compromising patient safety and care quality in the nursing process.
Choice D reason: Using clinical judgment to formulate problems is part of diagnosis, not assessment. Assessment collects raw data, while diagnosis analyzes it to identify issues. Assuming this conflates steps, risking incomplete data collection, which could result in inaccurate diagnoses and ineffective care plans, undermining the systematic approach of the nursing process.
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