The client diagnosed with primary hypertension says, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate?

You feel good because your medication is working properly.

Your blood pressure reflects how strong your heart muscle contracts.

Even if you are feeling good, damage can occur to your heart and kidneys.

Have you told your doctor that you are feeling good?

Answer and Explanation

The Correct Answer is C

Choice A reason: You feel good because your medication is working properly is not the most appropriate statement by the nurse. This statement may imply that the client does not need to worry about their blood pressure or follow up with their doctor. The nurse should educate the client about the importance of regular monitoring and adherence to the prescribed treatment.

Choice B reason: Your blood pressure reflects how strong your heart muscle contracts is not the most appropriate statement by the nurse. This statement may confuse the client or give them a false sense of security. The nurse should explain that blood pressure is determined by the force and amount of blood pumped by the heart and the resistance of the blood vessels. The nurse should also inform the client about the normal and abnormal ranges of blood pressure and the risk factors for hypertension.

Choice C reason: Even if you are feeling good, damage can occur to your heart and kidneys is the most appropriate statement by the nurse. This statement conveys the seriousness of hypertension and its potential complications. The nurse should educate the client about the effects of high blood pressure on the vital organs and the need for preventive measures and lifestyle modifications.

Choice D reason: Have you told your doctor that you are feeling good is not the most appropriate statement by the nurse. This statement may suggest that the nurse is not interested in the client's condition or does not have the knowledge or authority to address their concerns. The nurse should communicate effectively with the client and the health care team and provide appropriate guidance and support.

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Correct Answer is A

Explanation

Choice A reason: The client requires additional teaching if they state that they can have aspirin for pain after the bone marrow aspiration. Aspirin is a drug that inhibits platelet aggregation and increases the risk of bleeding. ¹ The client should avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) for at least 48 hours after the procedure. ² The client should use acetaminophen or another pain reliever that does not affect blood clotting.

Choice B reason: The client does not require additional teaching if they state that the nurse will check the puncture site at least every 4 hours after the procedure. This is a correct statement, as the nurse should monitor the site for signs of bleeding, infection, or hematoma. ² The nurse should also apply pressure and a sterile dressing to the site and instruct the client to keep it dry and clean for 24 hours.

Choice C reason: The client does not require additional teaching if they state that they will have some pain that is similar to a toothache. This is a correct statement, as the client may experience mild to moderate pain at the site of the aspiration, which may radiate to the hip or back. ² The pain usually subsides within a few hours or days.

Choice D reason: The client does not require additional teaching if they state that they understand that this is a sterile procedure. This is a correct statement, as the bone marrow aspiration is performed under sterile conditions to prevent infection. ² The nurse should wear gloves, gown, mask, and eye protection and use a sterile needle, syringe, and antiseptic solution.

A. have a urinary output of greater than 30 mL per hour for 24 hours. B. discuss which lifestyle modifications will be necessary to maintain health. C. express no complaints of chest discomfort or shortness of breath. D. have clear breath sounds bilaterally upon auscultation.

Correct Answer is C

Explanation

Choice A reason: Having a urinary output of greater than 30 mL per hour for 24 hours is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of fluid volume excess or renal impairment, which are not the case for this client.

Choice B reason: Discussing which lifestyle modifications will be necessary to maintain health is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of knowledge deficit or risk for recurrence, which are not the priority for this client.

Choice C reason: Expressing no complaints of chest discomfort or shortness of breath is the most appropriate outcome for the problem of impaired tissue perfusion. This outcome indicates that the client's cardiac output and oxygen delivery are adequate and that the interventions are effective.

Choice D reason: Having clear breath sounds bilaterally upon auscultation is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of impaired gas exchange or pulmonary congestion, which are not the case for this client.

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The client diagnosed with primary hypertension says, "I don't know why the doctor is worried about my blood pressure. I am feeling just fine." Which statement by the nurse would be the most appropriate?

Nursing Test Bank

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