At a community health fair, the blood pressure of a 62-year-old patient is 160/96 mmHg. The patient states "My blood pressure is usually much lower." What is the best response by the nurse?
Have your blood pressure checked again in 2 months.
Have your blood pressure checked within the next 48-72 hours.
Visit your health care provider within 1 week for a blood pressure check.
See your health care provider immediately.
The Correct Answer is D
A. This response may downplay the significance of the current elevated blood pressure reading. Given that the reading indicates stage 2 hypertension, waiting two months without further assessment could be inappropriate, as the patient may be at risk for complications.
B. This option suggests a follow-up in a reasonable timeframe. It acknowledges the need for a prompt reassessment but still allows for some delay. However, it may not convey the urgency that may be warranted given the current high reading.
C. While this option provides a specific timeframe for follow-up, it may also imply that the situation is less urgent than it is. A week could be too long to wait for someone with a reading indicative of hypertension, especially considering potential risks.
D. This is the best response because it prioritizes the patient's health by recommending immediate evaluation. The current blood pressure reading of 160/96 mmHg is significantly elevated and may warrant urgent assessment to rule out any underlying conditions, initiate management, and prevent complications such as cardiovascular events.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypertension, or high blood pressure, is a common condition in older adults but is not a specific indicator of pneumonia. While blood pressure can fluctuate with illness, it does not directly relate to the diagnosis of pneumonia.
B. Acute confusion is a critical and relevant sign in older adults with pneumonia. This demographic may experience altered mental status due to factors like hypoxia (low oxygen levels), fever, or dehydration. Confusion is often one of the first signs of infection in older patients, making it a significant assessment finding.
C. Hematemesis, which is the vomiting of blood, is not associated with pneumonia. It typically indicates a gastrointestinal issue, such as bleeding from ulcers or varices, rather than respiratory problems. Therefore, this finding would not be relevant to a pneumonia diagnosis.
D. While a cough is indeed a symptom of pneumonia, a dry hacking cough is less typical. Pneumonia generally presents with a productive cough (producing sputum) rather than a dry cough. A dry cough might suggest conditions like bronchitis or asthma.
Correct Answer is ["A","D","E"]
Explanation
A. It is important to place a surgical mask on the patient when transporting them to minimize the risk of spreading TB droplets in the environment. This practice helps reduce transmission during transport.
B. TB is primarily transmitted via airborne particles, not droplets. Therefore, patients with active TB should be placed on airborne precautions, not droplet precautions. Airborne precautions include the use of specialized masks and a negative airflow room to prevent the spread of infectious aerosols.
C. While a surgical mask is not adequate for protecting healthcare workers from TB, they should wear a fitted N95 respirator or a powered air-purifying respirator (PAPR) when providing care to a patient with active TB. A surgical mask does not filter out the small particles that can carry TB bacteria.
D. Patients with active TB should be placed in a private room that has negative pressure ventilation. This design helps prevent airborne TB particles from escaping into other areas of the healthcare facility, protecting other patients and staff.
E. Eye protection is recommended when collecting sputum samples from a patient with active TB, as it helps protect against potential splashes of respiratory secretions that may contain infectious droplets. This is particularly important during procedures that may aerosolize the bacteria.
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