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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
While suggesting that the patient get a walker might help with mobility, it does not directly address the safety concerns in the home environment.
Choice B rationale
A medical alert device could be beneficial in case of emergencies, but it does not prevent the risk of falls or accidents in the home.
Choice C rationale
Ensuring the patient’s privacy is important, but it does not address the immediate safety concerns observed by the nurse.
Choice D rationale
Identifying potential safety hazards in the home is the most immediate and effective action the nurse can take. By doing this, the nurse can work with the patient and their family to make necessary changes to improve safety and prevent falls.
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
Converting written vehicle instructions into a pictorial format can help improve understanding, but it does not directly address the physical dangers associated with the machinery.
Choice B rationale
Educating farm workers not to smoke around farm equipment can prevent fires, but it does not directly reduce the risk of machinery-related injuries.
Choice C rationale
Offering rehabilitation services to injured farm workers is important, but it is a reactive measure. The goal should be to prevent injuries from occurring in the first place.
Choice D rationale
Collaborating with lawmakers to mandate safe tractor design can have a significant impact on reducing farm machinery injuries. By addressing the issue at the design level, many injuries can be prevented.
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