Nokea
The nurse is caring for a client who is ordered diazoxide IV to decrease blood pressure. Which nursing consideration is a priority?
- A. Elevate the head of the bed.
- B. Use an automatic blood pressure recording machine.
- C. Place a Foley catheter to monitor urine output.
- D. Assess the client's deep tendon reflex.
Correct Answer: B
Rationale: A nursing priority is to monitor the client's blood pressure every few minutes. It is unrealistic to have the nurse manually assess the blood pressures. An automatic blood pressure machine is programed to assess the blood pressure and record the results for assessment. The other options may be completed; however, monitoring the blood pressure is the priority.
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The nurse is evaluating the types of medications prescribed for a client's hypertension. Which of the following medication classifications establishes an action on vasoconstrictive hormones in the blood stream?
- A. Beta-blocker
- B. ACE inhibitor
- C. Loop diuretic
- D. Calcium channel blocker
Correct Answer: B
Rationale: The angiotensin-converting enzyme (ACE) inhibitor's primary action is to prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstricting hormone in the blood. A beta-blocker blocks the beta-adrenergic receptors decreasing sympathetic nervous system stimulation. Loop diuretics excrete water from the loop of Henle, reducing circulating blood volume. Calcium channel blockers dilate coronary and peripheral arteries.
The nurse is caring for a client diagnosed with secondary hypertension. What would be a predisposing condition for this diagnosis?
- A. Use of diazepam
- B. Hypoaldosteronism
- C. Pancreatic disease
- D. Use of oral contraceptives
Correct Answer: D
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. Secondary hypertension is not caused by the use of sedatives, hypoaldosteronism, or pancreatic disease.
The nurse is caring for a client with essential hypertension. The nurse reviews lab work and assesses kidney function. Which action of the kidney would the nurse evaluate as the body's attempt to regulate high blood pressure?
- A. The kidney retains sodium and water.
- B. The kidney excretes sodium and water.
- C. The kidney retains sodium and excretes water.
- D. The kidney retains water and excretes sodium.
Correct Answer: B
Rationale: Hypernatremia (elevated serum sodium level) increases blood volume, which raises blood pressure. The kidney's response to the elevation in blood pressure is to excrete sodium and excess water. Any retention of sodium and water would increase blood volume and, thus, blood pressure. Sodium and water move together.
The nurse is volunteering at a community blood pressure screening. A client, never diagnosed with hypertension, presents with a blood pressure of $158 / 90 \mathrm{~mm} \mathrm{Hg}$. Which assessment question(s) is appropriate for the nurse to ask? Select all that apply.
- A. Have you recently drunk a caffeinated beverage?
- B. Did you have a beer after work?
- C. Do you smoke?
- D. Do you have a friend accompanying you?
- E. Are you married and with children?
Correct Answer: A,C
Rationale: At a community blood pressure clinic, the nurse would assess for common factors for a blood pressure to be elevated. Factors that can affect blood pressures readings include smoking or drinking coffee within 30 minutes of the reading. One beer after work should not affect the blood pressure reading, and some individuals may find it relaxing. Social situations are difficult to assess in a community blood pressure clinic.
The nurse is caring for a client with long-standing hypertension. As a client advocate, what should the nurse suggest that is most helpful in preventing further complications?
- A. Maintain a healthy diet of fruits and vegetables.
- B. Focus on exercise at least twice a week.
- C. Obtain a regular appointment with eye doctor.
- D. Avoid use of caffeinated beverages.
Correct Answer: C
Rationale: When a client has long-standing hypertension, the high blood pressure damages the arterial vascular system. As a client advocate, the nurse must instruct on not only prevention but also on early identification of complications. Damages may occur to the tiny arteries in the eyes compromising vision. The most helpful instruction is to maintain a regular appointment with an eye doctor. The other options are good instruction for a healthy lifestyle.