The client diagnosed with primary hypertension states, "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 response?

Your blood pressure reflects how strong your heart muscle contracts."

"If you feel good your medication is working properly"

"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

A. Your blood pressure reflects how strong your heart muscle contracts: This statement oversimplifies the complexities of blood pressure and doesn't directly address the client's misunderstanding about the implications of hypertension.

B. "If you feel good your medication is working properly": While this may be true, it fails to convey the importance of monitoring blood pressure, regardless of symptoms. It might lead the client to believe that feeling well means there are no health concerns.

C. "Even if you are feeling good, damage can occur to your heart and kidneys": This response is the most appropriate as it emphasizes that hypertension can cause silent damage over time, even in the absence of symptoms. It educates the client about the potential long-term consequences of uncontrolled hypertension.

D. "Have you told your doctor that you are feeling good?": While it encourages communication, it does not provide useful information or address the client’s misconceptions about hypertension and its risks.

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Correct Answer is B

Explanation

A. Decrease allergic reactions: Nitrate-free periods are not primarily designed to address allergic reactions.

B. Decrease tolerance to effects: Nitrates, including isosorbide mononitrate, can lead to the development of tolerance when used continuously. The nitrate-free period helps to minimize this tolerance, allowing the medication to remain effective over time.

C. Prevent reflex tachycardia: While nitrate use can sometimes cause reflex tachycardia, the nitrate-free interval is not specifically aimed at preventing this.

D. Increase absorption: The nitrate-free period does not influence the absorption of the medication itself.

A. Allow for rest periods between activities throughout the day B. Provide supplemental oxygen when the pulse oximetry falls below 96% C. Perform serial neurologic assessments to maintain safety and prevent injury D. Assess ability to perform activities of daily living (ADLS) E. Monitor blood pressure, pulse and respirations after activity

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

Explanation

A) Allow for rest periods between activities throughout the day: This intervention is essential for a client with activity intolerance. Incorporating rest periods helps to manage fatigue and allows for recovery, particularly when hypoxemia is a concern due to sickle cell anemia.
B) Provide supplemental oxygen when the pulse oximetry falls below 96%: Administering supplemental oxygen when oxygen saturation levels drop below 96% is crucial for preventing further hypoxemia and ensuring adequate tissue perfusion, thus addressing the client's activity intolerance.

C) Perform serial neurologic assessments to maintain safety and prevent injury: Regular neurologic assessments are vital, especially in clients with sickle cell anemia, who are at risk for complications like stroke. This intervention helps monitor for changes in neurological status, ensuring prompt action if needed.

D) Assess ability to perform activities of daily living (ADLs): Evaluating the client’s ability to perform ADLs provides valuable information on their functional status and helps tailor interventions to promote independence while considering their limitations due to hypoxemia.

E) Monitor blood pressure, pulse, and respirations after activity: This monitoring is important to evaluate the client’s response to activity and to detect any changes that could indicate distress or worsening hypoxemia. This information helps guide further interventions and ensures the client’s safety.

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The client diagnosed with primary hypertension states, "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 response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Isosorbide mononitrate modified release formula is structured to provide a nitrate free period. The nurse understands that the rationale for this period is to:

Correct Answer is B

Explanation

The client problem of Activity Intolerance related to hypoxemia from sickling RBCs has been made for a client with sickle cell anemia. Which intervention should the nurse include in the plan of care? (SELECT ALL THAT APPLY)

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

Explanation

The client diagnosed with primary hypertension states, "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 response?

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