The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment question(s) is appropriate for the nurse to ask? Select all that apply.

"Do you have a friend accompanying you?"

"Did you have a beer after work?"

"Do you smoke?"

"Are you married and with children?"

"Have you recently drunk a caffeinated beverage?"

Answer and Explanation

Correct Answer : B,C,E

A. "Do you have a friend accompanying you?": This question does not provide clinically relevant information for assessing elevated blood pressure. It focuses on social context rather than lifestyle or physiological contributors to hypertension.
B. "Did you have a beer after work?": Alcohol consumption can lead to acute and chronic elevations in blood pressure, especially with frequent intake. This question helps determine if the elevated reading is situational or requires further follow-up.
C. "Do you smoke?": Smoking leads to vasoconstriction, increases heart rate, and contributes to chronic vascular damage. Identifying tobacco use helps assess cardiovascular risk and guides education on modifiable factors.
D. "Are you married and with children?": This question relates to the client's social and family situation, which can indirectly influence stress levels and lifestyle choices, but it's not a direct physiological factor that would immediately explain an elevated blood pressure reading at a screening.
E. "Have you recently drunk a caffeinated beverage?": Caffeine can temporarily raise blood pressure, particularly in those not habituated to it. Understanding caffeine intake helps determine whether the current blood pressure is transient or a potential early sign of hypertension.

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Correct Answer is B

Explanation

A. A grilled chicken sandwich with mayonnaise: While some sodium is present in bread and condiments, grilled chicken and mayonnaise generally contain moderate sodium levels. With portion control and low-sodium ingredients, this can fit into a restricted sodium diet.
B. A hot dog with ketchup: Hot dogs are highly processed and contain high amounts of sodium and preservatives. Ketchup adds even more sodium, making this combination unsuitable for clients on a low sodium diet.
C. A natural fruit salad with nuts: Fresh fruits are naturally low in sodium, and unsalted nuts can be included as well. This option is both heart-healthy and supportive of a low sodium dietary plan.
D. A fresh grilled tuna entrée with fresh asparagus: When prepared without canned or pre-seasoned components, fresh tuna and vegetables are low in sodium. This meal provides lean protein and nutrients without excess salt.

A. Dyspnea when ambulating from the bathroom B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration C. Pulsus paradoxus on vital sign assessment D. Cyanosis with a pulse oximetry level of 92%

Correct Answer is C

Explanation

A. Dyspnea when ambulating from the bathroom: Mild exertional dyspnea is common in cardiac clients and may not require immediate provider notification unless it worsens or becomes unrelieved with rest.
B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration: An irregular pulse may warrant holding the medication and further assessment, but it is not always an emergency unless associated with hemodynamic instability or bradycardia.
C. Pulsus paradoxus on vital sign assessment: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, may indicate cardiac tamponade or severe pericardial effusion. It is a critical finding that requires immediate medical attention.
D. Cyanosis with a pulse oximetry level of 92%: While cyanosis is concerning, a SpO₂ of 92% may be acceptable for some cardiac or pulmonary patients. Further monitoring is needed, but it may not require urgent notification unless oxygen levels drop further.

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The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of 158/90 mm Hg. Which assessment question(s) is appropriate for the nurse to ask? Select all that apply.

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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