Nokea
A patient with newly diagnosed hypertension has come to the clinic for a follow-up visit. The patient asks the nurse why she has to come in so often. What would be the nurses best response?
- A. We do this so you dont suffer a stroke
- B. We do this to determine how your blood pressure changes throughout the day
- C. We do this to see how often you should change your medication dose
- D. We do this to make sure your health is stable. Well then monitor it at routinely scheduled intervals
Correct Answer: D
Rationale: When hypertension is initially detected, nursing assessment involves carefully monitoring the BP at frequent intervals and then at routinely scheduled intervals. The reference to stroke is frightening and does not capture the overall rationale for the monitoring regimen. Changes throughout the day are not a clinical priority for most patients. The patient must not change his or her medication doses unilaterally.
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A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group?
- A. Pacific Islanders
- B. African Americans
- C. Asian-Americans
- D. Hispanics
Correct Answer: D
Rationale: The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having the highest prevalence at approximately 63% and 57%, respectively.
The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions?
- A. Measuring the BP after the patient has been seated quietly for more than 5 minutes
- B. Taking the BP at least 10 minutes after nicotine or coffee ingestion
- C. Using a cuff with a bladder that encircles at least 80% of the limb
- D. Using a bare forearm supported at heart level on a firm surface
Correct Answer: B
Rationale: Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.
The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal?
- A. Less than 140/90 mm Hg
- B. Less than 130/90 mm Hg
- C. Less than 129/89 mm Hg
- D. Less than 120/80 mm Hg
Correct Answer: D
Rationale: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension.
An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurses health education should include which of the following?
- A. Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker
- B. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage
- C. Use of strategies to prevent falls stemming from postural hypotension
- D. Limiting exercise to avoid injury that can be caused by increased intracranial pressure
Correct Answer: C
Rationale: Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.
A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what?
- A. Retinal blood vessel damage
- B. Glaucoma
- C. Cranial nerve damage
- D. Hypertensive emergency
Correct Answer: A
Rationale: Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset.