During a health screening, a patient's blood pressure is confirmed by two clinic nurses to be 220/120 mm Hg. Which of the following actions should the nurse recommend to the patient?
“Take off work for the rest of the day to rest at home."
"Return to work and have your blood pressure rechecked in 2 days."
"Take two doses of blood pressure medication right now."
"Sit quietly while we call 911 to request an ambulance."
The Correct Answer is D
A. “Take off work for the rest of the day to rest at home.": This advice is not adequate for such a high blood pressure reading, which indicates a hypertensive crisis that requires immediate medical intervention.
B. "Return to work and have your blood pressure rechecked in 2 days.": This is inappropriate as it delays necessary urgent medical evaluation and treatment.
C. "Take two doses of blood pressure medication right now.": Without medical supervision, this could be dangerous and is not appropriate in an emergency situation where the blood pressure is critically high.
D. "Sit quietly while we call 911 to request an ambulance.": A blood pressure of 220/120 mm Hg suggests a hypertensive emergency, which can lead to life-threatening complications like stroke or heart attack. The patient needs immediate medical attention, and calling 911 is the appropriate response.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Transient ischemic attack (TIA): A TIA might cause transient symptoms similar to a stroke, including weakness and dysphasia, but it would not explain why the symptoms are localized to the right side of the body. Additionally, TIA symptoms typically resolve within 24 hours.
B. Basilar artery syndrome: This type of stroke affects the brain stem, resulting in symptoms such as double vision, vertigo, and ataxia, rather than localized right-sided weakness and dysphasia.
C. Left middle cerebral artery syndrome: The left middle cerebral artery (MCA) supplies blood to the left hemisphere of the brain, including areas that control language and motor function on the right side of the body. Thus, an infarct in this area often leads to right-sided weakness and dysphasia, making it the most likely suspect.
D. Right middle cerebral artery syndrome: This would typically result in left-sided weakness and possibly neglect, but not right-sided symptoms
Correct Answer is B
Explanation
A. Increase the client's oral fluid intake.: While staying hydrated is generally good, it doesn't directly address the issue of cold feet caused by reduced circulation.
B. Obtain a pair of slipper socks for the client.: Slipper socks can help keep the feet warm without constricting blood flow, which is important for comfort and promoting circulation.
C. Rub the client's feet briskly for several minutes.: Vigorous rubbing could potentially cause injury or worsen circulation issues due to the fragility of the tissues in vascular compromise.
D. Place a moist heating pad under the client's feet.: Moist heat is not recommended as it can increase the risk of burns and injury, especially if the client has reduced sensation due to vascular occlusion.
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