Nokea
The nurse and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question is most important for the nurse to ask?
- A. Who eats meals with you?
- B. How do you prepare your food?
- C. Do you eat three meals per day?
- D. Do you snack in the evening?
Correct Answer: B
Rationale: Asking the client how food is prepared gives the nurse and dietitian the ability to judge the sodium content. Typically, canned or prepared food and food from a restaurant will have elevated sodium levels. Sodium content in food prepared from fresh ingredients is usually minimal. Asking about whom the client eats with or the client's eating patterns are not as helpful in determining sodium content.
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The nurse in an oncology clinic notes that the client being treated has hypertension. What tumor is a predisposing condition for secondary hypertension?
- A. Pheochromocytoma
- B. Wilms' tumor
- C. Astrocytoma
- D. Lymphoma
Correct Answer: A
Rationale: Predisposing conditions include kidney disease, pheochromocytoma (a tumor of the adrenal medulla), hyperaldosteronism (increased secretion of mineralocorticoid by the adrenal cortex), atherosclerosis, use of cocaine or other cardiac stimulants (e.g., weight-control drugs, caffeine), and use of oral contraceptives. Wilms' tumors, astrocytomas, and lymphomas are not predisposing conditions for secondary hypertension.
The nurse is caring for a client with malignant hypertension. What would be an appropriate nursing intervention for this client?
- A. Monitor the client's mental and emotional status every hour.
- B. Monitor the blood pressure (BP) every few minutes by applying an automatic BP recording machine.
- C. Monitor the client's blood sugar every hour.
- D. Monitor the client's temperature every few minutes.
Correct Answer: B
Rationale: The nurse applies an automatic BP recording machine to the arm to measure the BP every few minutes. The nurse also keeps emergency equipment and drugs ready in case complications develop. Monitoring the client's mental and emotional status, blood sugar, or temperature every few minutes will not reflect the sudden rise in BP of a client with malignant hypertension.
The nurse obtains a blood pressure of $136 / 86 \mathrm{~mm} \mathrm{Hg}$ on a morning assessment of a client with history of hypertension. Which pressure is of most concern when considering ventricular relaxation?
- A. Central aortic pressure
- B. Systolic pressure
- C. Diastolic pressure
- D. Central venous pressure
Correct Answer: C
Rationale: Diastolic blood pressure reflects arterial pressure during ventricular relaxation. It depends on the resistance of the arterioles and the diastolic filing times. Central aortic pressure is the blood pressure pumped from the left ventricle and measured at the root of the aorta. Systolic blood pressure is determined by the force and volume of blood that the left ventricle ejects. Central venous pressure reflects the blood pressure returning to the heart.
The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client?
- A. peripheral edema
- B. right-sided heart failure
- C. stroke
- D. pulmonary insufficiency
Correct Answer: C
Rationale: A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock. Peripheral edema, right-sided heart failure, and pulmonary insufficiency are not usually consequences of untreated chronic hypertension.
The nurse is teaching a health class at the local community center. What body system would the nurse explain regulates arterial blood pressure?
- A. Cardiovascular system
- B. Immune system
- C. Lymphatic system
- D. Autonomic nervous system
Correct Answer: D
Rationale: The autonomic nervous system, the kidneys, and various endocrine glands regulate arterial pressure. The cardiovascular system, immune system, and lymphatic systems do not regulate arterial blood pressure.