A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 130/82 mm Hg places him in which of the following categories?
Within the expected reference range
Elevated
Stage 2 hypertension
Stage 1 hypertension
The Correct Answer is B
A. Within the expected reference range: While a blood pressure of 130/82 mm Hg is close to normal, it is not considered fully within the expected reference range. The normal range is typically defined as less than 120/80 mm Hg.
B. Elevated: The reading of 130/82 mm Hg falls into the "elevated" category, which is defined as systolic blood pressure between 120-129 mm Hg and diastolic pressure less than 80 mm Hg. This indicates that while the client is not hypertensive, they are at increased risk for developing hypertension in the future.
C. Stage 2 hypertension: This category is defined by a systolic reading of 140 mm Hg or higher, or a diastolic reading of 90 mm Hg or higher. The client’s reading does not meet these criteria, so this option is not applicable.
D. Stage 1 hypertension: Stage 1 hypertension is characterized by systolic readings between 130-139 mm Hg and diastolic readings between 80-89 mm Hg. Although the systolic reading is in the Stage 1 range, the diastolic reading of 82 mm Hg places the overall reading in the "elevated" category, rather than Stage 1 hypertension.
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Correct Answer is C
Explanation
A) Apply cold therapy to the affected leg: Cold therapy may be used for certain conditions to reduce swelling and pain, but in the case of suspected deep vein thrombosis (DVT) indicated by redness, warmth, tenderness, and pain in the calf, cold therapy is not appropriate. Instead, the focus should be on confirming the diagnosis before applying any treatment.
B) Monitor Homan's sign: Homan's sign involves dorsiflexion of the foot to assess for pain in the calf, which can suggest DVT. However, it is no longer considered a reliable diagnostic tool. Instead, confirmation through imaging or other diagnostic measures is preferred, so simply monitoring this sign would not be sufficient in this situation.
C) Obtain a venous duplex ultrasound: A venous duplex ultrasound is the gold standard for
diagnosing DVT. Given the client’s symptoms—redness, warmth, tenderness, and pain in the calf—the appropriate order is to obtain this ultrasound to confirm the presence of a thrombus. This imaging study provides critical information for diagnosis and subsequent management.
D) Obtain impedance plethysmography: While impedance plethysmography can assess venous flow and help diagnose DVT, it is less commonly used than venous duplex ultrasound. The more direct and widely accepted method for diagnosing DVT in this scenario is the ultrasound, making this option less suitable as the initial order.
Correct Answer is ["A","B","C","D"]
Explanation
A) "I will apply my compression stockings." Compression stockings are a standard recommendation for clients with peripheral venous disease (PVD). They help improve venous return and reduce symptoms like swelling and discomfort, indicating that the client understands the importance of managing their condition.
B) "I will limit long periods of standing." This statement reflects an understanding of the need to avoid activities that can exacerbate venous stasis and contribute to worsening symptoms in PVD. Limiting long periods of standing helps promote better blood flow and reduces the risk of complications.
C) "I may develop a brownish discoloration to my lower extremities." This statement indicates an awareness of a potential complication of PVD, often caused by venous stasis and pooling of blood. Brownish discoloration, or stasis dermatitis, can occur in the lower extremities, showing the client’s understanding of the condition.
D) "With this problem, I may have lower extremity hair loss." This statement is accurate as well; hair loss on the lower extremities can occur with PVD due to reduced blood flow and oxygen supply to the tissues. This recognition indicates that the client understands the potential effects of their diagnosis.
E) "I will only take my cholesterol lowering medication every other day in the afternoon." This statement reflects a misunderstanding of medication management. Clients with PVD should take prescribed medications as directed to manage their condition effectively, and altering the dosing schedule without consulting a healthcare provider can lead to adverse outcomes.