Nokea
The nurse is assessing a patient who is being investigated for possible white coat hypertension. Which of the following actions should the nurse implement first?
- A. Schedule the patient for frequent BP checks in the clinic.
- B. Instruct the patient about the need to decrease stress levels.
- C. Tell the patient how to self-monitor and record BPs at home.
- D. Teach the patient about ambulatory blood pressure monitoring.
Correct Answer: C
Rationale: Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Frequent BP checks in the clinic are likely to be high in a patient with white coat hypertension. Ambulatory blood pressure monitoring may be used if the data from self-monitoring is unclear. Although elevated stress levels may contribute to hypertension, instructing the patient about this is unlikely to reduce BP.
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The nurse is caring for a 52-year-old patient who has no previous history of hypertension or other health problems and has suddenly developed a BP of 188/106 mm Hg. After reconfirming the BP, which of the following information is best for the nurse to tell the patient?
- A. A BP recheck should be scheduled in a few weeks.
- B. The dietary sodium and fat content should be decreased.
- C. There is an immediate danger of a stroke and hospitalization will be required.
- D. More diagnostic testing may be needed to determine the cause of the hypertension.
Correct Answer: D
Rationale: A sudden increase in BP in a patient over age 50 or under age 20 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need rapid treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake has contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.
The nurse is admitting a patient with a history of hypertension and is being treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor to the emergency department. The patient has symptoms of a severe headache and has a BP of 240/118 mm Hg. Which of the following questions should the nurse ask first?
- A. Did you take any acetaminophen today?
- B. Do you have any recent stressful events in your life?
- C. Have you been consistently taking your medications?
- D. Have you recently taken any antihistamine medications?
Correct Answer: C
Rationale: Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.
Which of the following assessment findings for a patient who is receiving furosemide to treat stage 2 hypertension is most important to report to the health care provider?
- A. Blood glucose level of 10 mmol/L
- B. Blood potassium level of 3.0 mmol/L
- C. Early morning BP reading of 164/96 mm Hg
- D. Orthostatic systolic BP decrease of 12 mm Hg
Correct Answer: B
Rationale: Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also indicate a need for collaborative interventions but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is common and will require intervention only if the patient is symptomatic.
Which of the following actions should the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient?
- A. Obtain a BP reading in each arm and average the results.
- B. Deflate the BP cuff at a rate of 5-10 mm Hg/second.
- C. Have the patient sit in a chair.
- D. Assist the patient to the supine position for BP measurements.
Correct Answer: C
Rationale: The patient should be seated to assess the initial BP and pulse. The BP is obtained in both arms, but the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2-3 mm Hg/second.
Which of the following nursing actions should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?
- A. Have the patient record dietary intake for 3 days.
- B. Give the patient a detailed list of low-sodium foods.
- C. Teach the patient about foods that are high in sodium.
- D. Help the patient make an appointment with a dietitian.
Correct Answer: A
Rationale: The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day diet history. The other actions may be appropriate, but assessment of the patient's baseline should occur first.