a nurse is caring for a client who has hypertension which approach is the priority when the nurse is measuring the clients blood pressure
Logo

Nursing Elites

HESI LPN

HESI Fundamentals Test Bank

1. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

2. The healthcare provider is caring for a client who has just been diagnosed with myasthenia gravis. Which symptom should the healthcare provider expect to observe?

Correct answer: A

Rationale: Muscle weakness is a hallmark symptom of myasthenia gravis, a neuromuscular disorder characterized by impaired neuromuscular transmission. This results in muscle weakness, particularly in skeletal muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. Joint pain (Choice B) is not a typical symptom of myasthenia gravis and is more commonly associated with conditions like arthritis. Vision changes (Choice C) may occur in conditions affecting the eyes, but they are not specific to myasthenia gravis. Skin rash (Choice D) is also not a typical manifestation of myasthenia gravis. Therefore, the correct answer is muscle weakness (Choice A).

3. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?

Correct answer: B

Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.

4. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?

Correct answer: A

Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.

5. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

Correct answer: C

Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.

Similar Questions

A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?
A client who has been experiencing frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse include in the client's plan of care?
The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?
A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?
A client has pharyngeal diphtheria. What transmission precautions are necessary?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses