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The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal?
- A. Less than 140/90 mm Hg
- B. Less than 130/90 mm Hg
- C. Less than 129/89 mm Hg
- D. Less than 120/80 mm Hg
Correct Answer: D
Rationale: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension.
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A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patients care, what desired outcome should the nurse identify?
- A. Patient takes medication as prescribed and reports any adverse effects
- B. Patients BP remains consistently below 140/90 mm Hg
- C. Patient denies signs and symptoms of hypertensive urgency
- D. Patient is able to describe modifiable risk factors for hypertension
Correct Answer: A
Rationale: The most appropriate expected outcome for a patient who is given the nursing diagnosis of risk for ineffective health maintenance is that he or she takes the medication as prescribed. The other listed goals are valid aspects of care, but none directly relates to the patients role in his or her treatment regimen.
A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency?
- A. Normalizing BP within 2 hours
- B. Obtaining a BP of less than 110/70 mm Hg within 36 hours
- C. Obtaining a BP of less than 120/80 mm Hg within 36 hours
- D. Normalizing BP within 24 to 48 hours
Correct Answer: D
Rationale: In cases of hypertensive urgency, oral agents can be administered with the goal of normalizing BP within 24 to 48 hours. For patients with this health problem, a BP of 120/80 mm Hg may be unrealistic.
A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurses most appropriate action?
- A. Add sodium to the patients IV fluid, as ordered
- B. Administer a vasoconstrictor, as ordered
- C. Promptly cease antihypertensive therapy
- D. Administer normal saline IV, as ordered
Correct Answer: D
Rationale: If there is volume depletion secondary to natriuresis caused by the elevated BP, then volume replacement with normal saline can prevent large, sudden drops in BP when antihypertensive medications are administered. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not normally indicated.
A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state?
- A. Avoid excessive potassium intake
- B. Exercise on a regular basis
- C. Eat less protein and more vegetables
- D. Limit morning activity
Correct Answer: B
Rationale: To prevent or delay progression to hypertension and reduce risk, JNC 7 urged health care providers to encourage people with blood pressures in the prehypertension category to begin lifestyle modifications, such as nutritional changes and exercise. There is no need for patients to limit their activity in the morning or to avoid potassium and protein intake.
The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply.
- A. Increased venous return
- B. Decreased peripheral resistance
- C. Decreased blood volume
- D. Decreased strength and rate of myocardial contractions
- E. Decreased blood viscosity
Correct Answer: B,C,D
Rationale: The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood viscosity.