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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.
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Which of the following nursing diagnoses is the nurse most correct to choose when caring for a client with long-standing hypertension?
- A. Impaired Gas Exchange
- B. Activity Intolerance
- C. Altered Tissue Perfusion
- D. Risk for Decreased Cardiac Output
Correct Answer: C
Rationale: The nurse is most correct in choosing Altered Tissue Perfusion for the client with long-standing hypertension. In hypertension, the extra work increases the size of the heart muscle. Eventually, the heart cannot meet the body's metabolic needs limiting the perfusion to the tissues. Impaired Gas Exchange, Activity Intolerance, and a Risk for Decreased Cardiac Output may occur due to the ineffective perfusion.
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.
The nurse would screen a client from which ethnic background for hypertension at an early age?
- A. Asian population
- B. Japanese population
- C. Mexican population
- D. Population of African descent
Correct Answer: D
Rationale: The population of African descent is at the highest risk for development of hypertension. The other ethnic backgrounds have a lower risk.
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.
What is blood pressure?
- A. The force produced by the volume of blood in arterial walls
- B. The force produced by the volume of blood in the venous system
- C. The measurement of cardiac output
- D. The peripheral resistance of the cardiac output
Correct Answer: A
Rationale: Blood pressure (BP) is the force produced by the volume of blood in arterial walls. It is represented by the formula: $\mathrm{BP}=\mathrm{CO}$ (cardiac output) PR (peripheral resistance). This makes the other options incorrect.