Nokea
The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first?
- A. Recommend that the client have his blood pressure checked in one (1) month.
- B. Instruct the client to see his health-care provider as soon as possible.
- C. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet.
- D. Explain that this BP is within the normal range for an elderly person.
Correct Answer: B
Rationale: BP 168/98 indicates stage 2 hypertension, requiring prompt HCP evaluation (B). Waiting a month (A) delays care, diet discussion (C) is secondary, and normal range (D) is incorrect (normal is <120/80).
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The nurse is assessing a client with mitral regurgitation. Which finding is expected?
- A. High-pitched holosystolic murmur
- B. Bradycardia
- C. Clear lung sounds
- D. Hypotension
Correct Answer: A
Rationale: Mitral regurgitation causes a high-pitched holosystolic murmur due to blood flowing back into the left atrium.
Which instruction should the nurse include for a client with valvular heart disease?
- A. Avoid high-sodium foods.
- B. Increase caffeine intake.
- C. Limit fluid intake.
- D. Avoid regular exercise.
Correct Answer: A
Rationale: Avoiding high-sodium foods prevents fluid retention, reducing strain on the heart.
The client with coronary artery disease reports chest pain. What should the nurse do first?
- A. Administer oxygen.
- B. Check vital signs.
- C. Give nitroglycerin as prescribed.
- D. Place the client in a supine position.
Correct Answer: C
Rationale: Nitroglycerin is the first-line treatment for angina to relieve chest pain by dilating coronary arteries.
The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first?
- A. Complete a neurovascular assessment.
- B. Use the Doppler device.
- C. Instruct the client to hang the feet off the side of the bed.
- D. Wrap the legs in a blanket.
Correct Answer: B
Rationale: Absent pedal pulse in PAD requires Doppler use (B) to confirm blood flow. Neurovascular assessment (A) follows, dependent position (C) worsens ischemia, and blankets (D) are irrelevant.
Which assessment finding indicates a worsening condition in a client with pericarditis?
- A. Muffled heart sounds
- B. Heart rate of 80 beats per minute
- C. Blood pressure of 120/80 mmHg
- D. Mild chest discomfort
Correct Answer: A
Rationale: Muffled heart sounds suggest pericardial effusion or cardiac tamponade, indicating worsening pericarditis.