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."

Answer and Explanation

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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Correct Answer is D

Explanation

A. Bilateral edema of the legs: While significant, bilateral edema is a common symptom of venous insufficiency and generally less urgent compared to signs of compromised circulation.
B. Bilateral hyperaemia of the legs: Hyperaemia (increased blood flow) is less concerning compared to cyanosis and coolness, which suggest severe impairment.
C. Bilateral full superficial leg veins: Prominent veins are typical in venous insufficiency and do not indicate an immediate threat.
D. Left leg cool, cyanotic skin: This is correct. Cool, cyanotic skin indicates poor perfusion and potential arterial involvement or severe venous congestion, requiring urgent assessment to prevent tissue damage.

A. Monitor blood glucose levels. B. Lifestyle modifications and medication adherence will not prevent blindness, C. Lifestyle modifications can prevent strokes. D. End organ damage is inevitable because of microvascular changes that occur. E. Take medications as ordered.

Correct Answer is ["A","C","E"]

Explanation

A. Monitor blood glucose levels: Patients with diabetes need to keep their blood glucose levels under control to prevent complications, including those that can exacerbate hypertension or lead to cardiovascular problems.
B. Lifestyle modifications and medication adherence will not prevent blindness: This is incorrect. Proper management of diabetes through lifestyle changes and medication adherence can help prevent complications like diabetic retinopathy, which can lead to blindness.
C. Lifestyle modifications can prevent strokes: Effective management of diabetes and hypertension through lifestyle changes (diet, exercise, smoking cessation) can significantly reduce the risk of strokes and other cardiovascular events.
D. End organ damage is inevitable because of microvascular changes that occur: This is misleading. While microvascular changes are a risk in diabetes, proper management and lifestyle modifications can greatly reduce the risk and progression of end-organ damage.
E. Take medications as ordered: Adherence to prescribed medications is crucial for controlling both blood glucose and blood pressure, reducing the risk of complications such as stroke, heart disease, and kidney damage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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