Nokea
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.
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Which of the following actions should the nurse include in the plan of care for a patient who is receiving IV nitroglycerine to treat a hypertensive emergency?
- A. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night.
- B. Assist the patient up in the chair for meals to avoid complications associated with immobility.
- C. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements.
- D. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.
Correct Answer: C
Rationale: Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 6 to 8 hours of undisturbed sleep is not appropriate. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.
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.
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.
The nurse obtains a blood pressure of 180/75 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?
- A. 110
- B. 120
- C. 130
- D. 140
Correct Answer: A
Rationale: MAP = (DBP + 1/3 Pulse pressure). For a BP of 180/75 mm Hg, pulse pressure = 180 - 75 = 105 mm Hg. MAP = 75 + (1/3 * 105) = 75 + 35 = 110 mm Hg.
Which of the following BP findings by the nurse indicate that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure?
- A. 108/64 mm Hg
- B. 128/76 mm Hg
- C. 140/90 mm Hg
- D. 136/82 mm Hg
Correct Answer: B
Rationale: The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse effects of drugs. The other two blood pressures indicate a need for modifications in the patient's treatment.