According to the JNC’s seventh report, a BP reading of 144/96 would be considered ______.
Normal
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
The Correct Answer is C
The Joint National Committee (JNC 7) report provides evidence-based guidelines for the classification and management of blood pressure (BP) to reduce the risk of cardiovascular disease.
Rationale for correct answer:
C. Stage 1 Hypertension: Stage 1 hypertension is defined as: Systolic 140–159 mmHg or Diastolic 90–99 mmHg.
Rationale for incorrect answers:
A. Normal: According to JNC 7, normal BP is defined as less than 120/80 mmHg.
B. Prehypertension is defined as: Systolic 120–139 mmHg or Diastolic 80–89 mmHg.
D. Stage 2 Hypertension is defined as: Systolic ≥160 mmHg or Diastolic ≥100 mmHg.
Take-home points:
- According to JNC 7, Stage 1 Hypertension is defined as a systolic BP of 140–159 mmHg or diastolic of 90–99 mmHg.
- When systolic and diastolic values fall into different categories, the higher stage should determine the classification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Pain, especially severe acute pain like abdominal pain, triggers a sympathetic nervous system (SNS) response, often referred to as the "fight or flight" reaction. This leads to measurable changes in vital signs.
Rationale for correct answer:
A. An increase in the pulse rate: Pain stimulates the sympathetic nervous system, resulting in tachycardia (increased heart rate).
Rationale for incorrect answers:
B. A decrease in body temperature: Pain does not typically cause a drop in temperature. Hypothermia is more likely in shock, exposure, or metabolic disorders-not as a direct result of pain.
C. A decrease in blood pressure: In the early stages of pain, the SNS response often causes a mild increase in blood pressure.
D. An increase in respiratory depth: Acute abdominal pain usually causes patients to take shallow breaths to minimize movement and discomfort (known as splinting).
Take-home points:
- Increased heart rate (tachycardia) is a common and expected physiological response to severe pain due to SNS activation.
- Nurses must interpret changes in vital signs in the context of the patient's symptoms to detect early signs of deterioration or complications.
Correct Answer is A
Explanation
The American Heart Association recommends selecting a cuff size based on the circumference of the patient’s upper arm, not just age or weight.
Rationale for correct answer:
A. An incorrect reading: Using the wrong cuff size is the most common error in BP measurement. A cuff too small may falsely elevate the BP reading. A cuff too large may falsely lower the reading.
Rationale for incorrect answers:
B. Injury to the patient: While rare, prolonged or repeated inflation could cause discomfort, especially in fragile patients, but injury is uncommon due to cuff size alone.
C. Prolonged pressure on the arm: The duration of pressure is more related to how long the cuff is inflated, not its size.
D. Loss of Korotkoff sounds is typically related to improper stethoscope placement, cuff deflation speed, or poor technique, not cuff size alone.
Take-home points:
- Using the wrong cuff size results in inaccurate BP readings, which may lead to misdiagnosis and improper management.
- Always measure the mid-upper arm circumference and choose a cuff that covers 40% of the arm's width and 80% of its length for accuracy.
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