An older adult client visits the community health clinic, reporting the onset of pain, redness, and swelling in the right eye.
What is the most important for the clinic nurse to ask the client?

Answer and explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale

Encouraging the client to “keep doing whatever you are doing” is not an appropriate intervention for a client with a blood pressure reading of 138/80 mm Hg. This blood pressure reading is considered elevated and could indicate pre-hypertension. Therefore, the nurse should assess the client’s lifestyle and other risk factors for hypertension, ask the client about any current antihypertensive medications, obtain another blood pressure reading to verify the first reading, and recommend further evaluation for possible pre-hypertension.

Choice B rationale

Assessing the client’s lifestyle and other risk factors for hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Lifestyle factors, such as diet, physical activity, alcohol consumption, and tobacco use, can significantly influence

blood pressure levels. Therefore, the nurse should assess these factors and provide appropriate education and interventions.

Choice C rationale

Asking the client about any current antihypertensive medications is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. The client may be taking medications that could affect their blood pressure. Therefore, the nurse should ask about these medications and consider their potential impact on the client’s blood pressure.

Choice D rationale

Obtaining another blood pressure reading to verify the first reading is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Blood pressure can fluctuate throughout the day and can be influenced by various factors, such as stress, physical activity, and caffeine consumption. Therefore, the nurse should obtain another reading to confirm the initial measurement.

Choice E rationale

Recommending further evaluation for possible pre-hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. A blood pressure reading of 138/80 mm Hg is considered elevated and could indicate pre-hypertension. Therefore, the nurse should recommend further evaluation to confirm this diagnosis and determine appropriate treatment.

Answer and explanation The correct answer is D. Choice A rationale

Staying with someone for 10 hours post-injection is not a standard recommendation after receiving the Hepatitis B Vaccine (HBV). The vaccine is generally well-tolerated, and serious side effects are rare.

Choice B rationale

While it can be comforting to have a family member present during medical procedures, it is not necessary for the final injection of the HBV series.

Choice C rationale

While it is important to encourage vaccination among all eligible individuals, the immediate concern after healthcare workers receive the HBV is not about their family members’ vaccination status.

Choice D rationale

Regular monitoring of immunization levels is important after receiving the HBV series. This is because healthcare workers are at a higher risk of exposure to Hepatitis B, and ensuring immunity is crucial for their safety.