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The client diagnosed with essential hypertension asks the nurse, 'Why do I have high blood pressure?' Which response by the nurse would be most appropriate?
- A. You probably have some type of kidney disease that causes the high BP.'
- B. More than likely you have had a diet high in salt, fat, and cholesterol.'
- C. There is no specific cause for hypertension, but there are many known risk factors.'
- D. You are concerned that you have high blood pressure. Let's sit down and talk.'
Correct Answer: C
Rationale: Essential hypertension has no single cause but multiple risk factors (e.g., genetics, lifestyle) (C). Kidney disease (A) or diet (B) may contribute but aren’t definitive, and concern (D) avoids the question.
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The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
Which intervention should the nurse prioritize for a client with ventricular tachycardia?
- A. Administer lidocaine as prescribed.
- B. Check blood pressure.
- C. Encourage deep breathing.
- D. Apply oxygen at 2 L/min.
Correct Answer: A
Rationale: Lidocaine is used to suppress ventricular tachycardia, a life-threatening arrhythmia.
The nurse is teaching a client about heart failure medications. Which statement about furosemide (Lasix) is accurate?
- A. It strengthens your heart muscle.
- B. It lowers your blood pressure.
- C. It helps remove excess fluid.
- D. It prevents irregular heartbeats.
Correct Answer: C
Rationale: Furosemide is a loop diuretic that promotes fluid excretion, reducing preload in heart failure.
Which teaching point should the nurse include for a client with cardiomyopathy? Select all that apply.
- A. Monitor for signs of heart failure.
- B. Avoid alcohol consumption.
- C. Take medications as prescribed.
- D. Engage in high-intensity exercise.
- E. Report sudden weight gain.
- F. Limit fluid intake as advised.
Correct Answer: A,B,C,E,F
Rationale: Monitoring heart failure signs, avoiding alcohol, adhering to medications, reporting weight gain, and limiting fluids prevent complications.
The nurse is assessing a client with hypertension. Which finding requires immediate action?
- A. Blood pressure of 160/100 mmHg
- B. Headache rated 4/10
- C. Blurred vision and confusion
- D. Pulse rate of 88 beats per minute
Correct Answer: C
Rationale: Blurred vision and confusion indicate a hypertensive crisis, which can lead to organ damage and requires immediate intervention.