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The nurse is screening for hypertension at a local health fair.
A community resident has a blood pressure reading of 138/80 mm Hg. What interventions should the nurse implement for this client? Select all that apply.

Encourage the client to “keep doing whatever you are doing.”.

Assess the client’s lifestyle and other risk factors for hypertension.

Ask the client about any current antihypertensive medications.

Obtain another blood pressure reading to verify the first reading.

Recommend further evaluation for possible pre-hypertension.

Answer and Explanation

Correct Answer : B,C,D,E

Answer and explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale

Encouraging the client to “keep doing whatever you are doing” is not an appropriate intervention for a client with a blood pressure reading of 138/80 mm Hg. This blood pressure reading is considered elevated and could indicate pre-hypertension. Therefore, the nurse should assess the client’s lifestyle and other risk factors for hypertension, ask the client about any current antihypertensive medications, obtain another blood pressure reading to verify the first reading, and recommend further evaluation for possible pre-hypertension.

Choice B rationale

Assessing the client’s lifestyle and other risk factors for hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Lifestyle factors, such as diet, physical activity, alcohol consumption, and tobacco use, can significantly influence

blood pressure levels. Therefore, the nurse should assess these factors and provide appropriate education and interventions.

Choice C rationale

Asking the client about any current antihypertensive medications is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. The client may be taking medications that could affect their blood pressure. Therefore, the nurse should ask about these medications and consider their potential impact on the client’s blood pressure.

Choice D rationale

Obtaining another blood pressure reading to verify the first reading is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. Blood pressure can fluctuate throughout the day and can be influenced by various factors, such as stress, physical activity, and caffeine consumption. Therefore, the nurse should obtain another reading to confirm the initial measurement.

Choice E rationale

Recommending further evaluation for possible pre-hypertension is an important intervention for a client with a blood pressure reading of 138/80 mm Hg. A blood pressure reading of 138/80 mm Hg is considered elevated and could indicate pre-hypertension. Therefore, the nurse should recommend further evaluation to confirm this diagnosis and determine appropriate treatment.

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Correct Answer is B

Explanation

Answer and explanation

The correct answer is Choice B.

Choice A rationale

While reinforcing instructions can boost a patient’s self-confidence, it may not be effective for an elderly patient with Parkinson’s disease who is unable to administer ophthalmic medication due to hand tremors. The physical limitation caused by the tremors may not be overcome by further instruction.

Choice B rationale

If a family member is available and willing to administer the medication, this could be an effective solution. The family member can be trained to administer the medication correctly, ensuring the patient receives their necessary treatment.

Choice C rationale

While obtaining a prescription for a visiting nurse to administer the medication twice a day could ensure the patient receives their medication, it may not be the most practical or cost- effective solution. It also depends on the availability of such services in the patient’s area.

Choice D rationale

Documenting the patient’s inability to administer the medication without assistance is important for record-keeping and communicating with other healthcare providers. However, it does not address the immediate issue of ensuring the patient receives their necessary medication.

A. Demonstrate proper foot care to the client and family. B. Gradually trim the client’s toenails over several visits. C. Arrange for a home health aide to assist the client with hygiene weekly. D. Schedule an appointment for the client with a podiatrist.

Correct Answer is D

Explanation

Answer and explanation

The correct answer is Choice D.

Choice A rationale

While demonstrating proper foot care is important, this client’s situation requires immediate attention. Long, thick nails that curl under the toes can lead to complications such as ulcers, infections, and pain.

Choice B rationale

Gradually trimming the client’s toenails over several visits may not be the best approach. The client’s long, thick nails are causing discomfort and could lead to more serious complications.

Choice C rationale

Arranging for a home health aide to assist the client with hygiene weekly could be part of a long-term plan, but it does not address the immediate issue of the client’s long, thick toenails.

Choice D rationale

Scheduling an appointment for the client with a podiatrist is the best option. A podiatrist is a healthcare professional who specializes in foot care. They can safely trim the client’s long, thick toenails and assess for any other foot-related issues.

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The nurse is screening for hypertension at a local health fair.A community resident has a blood pressure reading of 138/80 mm Hg. What interventions should the nurse implement for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Despite numerous instructions, an elderly patient with Parkinson’s disease is unable to administer ophthalmic medication without assistance due to hand tremors.What is the best course of action for the nurse?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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The nurse is screening for hypertension at a local health fair.
A community resident has a blood pressure reading of 138/80 mm Hg. What interventions should the nurse implement for this client? Select all that apply.