Nokea
An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg.
A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?
- A. Remeasure the client's blood pressure.
- B. Administer an antihypertensive medication.
- C. Report the blood pressure reading to the charge nurse.
- D. Instruct the client to remain in bed.
Correct Answer: A
Rationale: Remeasuring verifies the accuracy of the elevated reading before further action.
You may also like to solve these questions
A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should place my baby in the car seat at a 90-degree angle.
- B. I should keep my baby rear-facing in the car seat until she is 2 years old.
- C. I should position the car seat's retainer clip at the level of my baby's belly button.
- D. I should enable the airbag when my baby is in the front seat of the car.
Correct Answer: B
Rationale: Rear-facing until age 2 aligns with current safety guidelines.
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?
- A. Voice alteration
- B. Neck pain
- C. Tingling of the scalp
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect post-ECT.
The client reports manifestations of depression.
A nurse is collecting data from a client who reports manifestations of depression. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. The client is married and has children.
- B. The client has a strong religious affiliation.
- C. The client recently received a pay raise at work.
- D. The client has a history of chronic back pain.
Correct Answer: D
Rationale: Chronic pain increases suicide risk due to persistent distress.
The client is dependent on nicotine and wishes to discontinue smoking.
A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?
- A. Weight loss
- B. Diaphoresis
- C. Insomnia
- D. Diarrhea
Correct Answer: C
Rationale: Insomnia is a common nicotine withdrawal symptom.
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?
- A. Believes that his brother's death will be reversible
- B. Alienates himself from his peers
- C. Believes his bad behavior is causing his brother's death
- D. Regresses to an earlier developmental level
Correct Answer: A
Rationale: School-age children often see death as reversible, like sleep.