A 62-yr-old client who has no history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP.What is most appropriate for the nurse to tell the client

Correct Answer: C

Rationale: The correct answer is C because a sudden spike in blood pressure to 198/110 mm Hg is considered hypertensive crisis requiring immediate medical attention. The nurse should inform the client that diagnosis, treatment, and monitoring are necessary to address the high blood pressure. This is important to prevent serious complications like stroke or heart attack. Option A is incorrect because waiting a few weeks for a BP recheck could be dangerous in this scenario. Option B is also incorrect as simple dietary changes may not be sufficient to address such high blood pressure levels. Option D is incorrect as hospitalization may or may not be required based on the assessment and treatment plan determined by the healthcare provider.

Correct Answer: A

Rationale: After inspiration commences, the diaphragm contracts and the thoracic cavity expands. This leads to a decrease in intrapleural pressure, allowing the lungs to expand. Simultaneously, intrapulmonary pressure decreases, creating a pressure gradient for air to flow into the lungs. Choice A is correct because both intrapleural pressure and intrapulmonary pressure fall during inspiration. Choice B is incorrect because intrapulmonary pressure actually decreases during inspiration, not rises. Choice C is incorrect because intrapleural pressure falling does not directly correlate with a decrease in venous return. Choice D is incorrect because during inspiration, the volume of the alveoli increases as the lungs expand, causing intrapulmonary pressure to decrease.

Correct Answer: D

Rationale: The correct answer is D: internal respiration. This is the part of respiration where oxygen and carbon dioxide are exchanged in the body's tissue cells. During internal respiration, oxygen is delivered to the cells and carbon dioxide is removed. Pulmonary ventilation (choice A) refers to the process of breathing where air is moved in and out of the lungs. External respiration (choice B) is the exchange of gases between the lungs and blood. Transport of respiratory gases (choice C) involves the circulation of oxygen and carbon dioxide in the bloodstream. Internal respiration specifically focuses on the exchange of gases within the tissue cells, making it the correct choice in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Teaching the patient how to perform controlled coughing. This intervention helps to clear mucus and secretions from the airways, maintaining a patent airway. Controlled coughing also prevents airway obstruction and promotes effective breathing. Restricting fluid intake (A) can lead to dehydration and thickening of secretions, worsening airway clearance. Enforcing bed rest (B) can cause decreased lung expansion and retention of secretions. Administering sedatives (D) can depress respiratory drive and worsen respiratory function.

Correct Answer: C

Rationale: The correct answer is C: Decreased hearing acuity. Streptomycin is known to cause ototoxicity, which can lead to decreased hearing acuity. Therefore, the nurse should instruct the client to notify the physician if any changes in hearing occur to prevent permanent hearing loss. Impaired color discrimination (A) and increased appetite (D) are not commonly associated with streptomycin use. Increased urinary frequency (B) is not a typical side effect of streptomycin and would not require immediate physician notification.