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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incontinence (bowel or urinary): While incontinence may occur in stroke patients, it is not the primary concern for someone with hemianopsia, a visual impairment.
B. Impaired skin integrity: Although this is important, particularly for immobile patients, it is not directly related to hemianopsia.
C. Disturbed sensory perception: Hemianopsia results in the loss of half the field of vision in one or both eyes, leading to disturbed sensory perception. This is a priority because it directly affects the patient's ability to navigate their environment safely.
D. Imbalanced nutrition: Although important, this is not the immediate concern related to hemianopsia.
Correct Answer is D
Explanation
A. Instruct the patient to wear constrictive clothing: This is incorrect. Constrictive clothing can impede blood flow and worsen venous stasis.
B. Encourage frequent ambulation: This is correct. Ambulation promotes circulation, helps prevent blood stasis, and encourages the healing of ulcers.
C. Encourage the patient to keep legs in a dependent position: This is incorrect. Keeping the legs in a dependent position can increase venous pressure and exacerbate edema, which is counterproductive for managing venous stasis ulcers.
D. Apply compression stockings: This is correct. Compression stockings help to improve venous return, reduce edema, and promote ulcer healing by preventing blood from pooling in the legs.
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