The nurse is planning the care of a client who has been diagnosed with hypertension but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment?

120/80 mm Hg or lower.

Average of two BP readings of 150/80 mm Hg

140/90 mm Hg or lower

156/96 mm Hg or lower

Answer and Explanation

The Correct Answer is C

A. 120/80 mm Hg or lower:

This blood pressure range is considered normal or optimal for most adults. However, for individuals diagnosed with hypertension, the goal is typically to reduce blood pressure to below 140/90 mm Hg, as maintaining normal blood pressure is not considered a goal for hypertension treatment unless specifically indicated based on individual circumstances.

B. Average of two BP readings of 150/80 mm Hg:

A blood pressure reading of 150/80 mm Hg is elevated and indicates hypertension, especially if consistently elevated across multiple readings. The goal of hypertension treatment is to lower blood pressure to below 140/90 mm Hg, so an average of 150/80 mm Hg would not be considered the goal of treatment.

C. 140/90 mm Hg or lower:

This blood pressure range is commonly recommended as the goal of treatment for individuals with hypertension who otherwise enjoy good health. It represents a balance between effective blood pressure control and minimizing the risk of side effects or complications associated with overly aggressive treatment.

D. 156/96 mm Hg or lower:

While a blood pressure reading of 156/96 mm Hg is elevated and indicates hypertension, the goal of treatment is typically to reduce blood pressure to below 140/90 mm Hg rather than targeting a specific numeric value below 156/96 mm Hg.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Weigh yourself once a week:

This is an important part of heart failure management as weight gain can indicate fluid retention, a common symptom of heart failure. The nurse should instruct the client to weigh themselves at the same time of day, using the same scale, and wearing similar clothing each time. Any sudden weight gain should be reported to the healthcare provider promptly.

B. Drink 3 liters of fluid per day:

This option is not appropriate for most heart failure patients, especially those with fluid retention issues. Fluid intake should be monitored and restricted based on the individual's condition and healthcare provider's recommendations. Consuming too much fluid can exacerbate fluid retention and worsen heart failure symptoms.

C. Engage in exercise daily:

Exercise is generally recommended for heart failure patients, but the type, intensity, and frequency of exercise should be tailored to the individual's condition. The nurse should encourage the client to engage in regular physical activity as tolerated, following a structured exercise plan approved by their healthcare provider. Activities like walking, cycling, or water aerobics can be beneficial for heart health.

D. Restrict dietary potassium:

This option is not typically included in lifestyle modifications for heart failure unless the client has specific potassium-related issues or is taking medications that require potassium restriction. Potassium is an important electrolyte for heart function, and most heart failure patients are advised to consume a balanced diet with moderate potassium intake, unless otherwise directed by their healthcare provider.

A. Monitor weight daily B. Assess radial pulses daily C. Monitor bowel movements D. Monitor blood pressure daily

Correct Answer is A

Explanation

A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.

B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.

C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.

D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.

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The nurse is planning the care of a client who has been diagnosed with hypertension but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment?

Nursing Test Bank

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