Nokea
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.
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The nurse is employed in a physician's office and is caring for a client present for an annual exam. A blood pressure of $124 / 84 \mathrm{~mm} \mathrm{Hg}$ is documented. Following revised guidelines for identifying hypertension, which educational pamphlet is helpful?
- A. Increasing fluids for low blood pressure
- B. Stress reduction to lower prehypertensive state
- C. Use of beta-blockers for treatment of hypertension
- D. Diagnostic testing for determining cardiac functioning
Correct Answer: B
Rationale: A blood pressure of $124 / 84 \mathrm{~mm} \mathrm{Hg}$ is now considered to be in the lower range of prehypertension. Knowledge of stress reduction may be helpful in lowering the blood pressure without medication therapy. A blood pressure of $124 / 84 \mathrm{~mm} \mathrm{Hg}$ is not considered a low blood pressure or in need of medication therapy due to hypertension. Diagnostic testing for cardiac functioning is not typical for a client with prehypertension.
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 and a dietitian are instructing the client on a low-sodium diet needed to lower the blood pressure. Which question is most important for the nurse to ask?
- A. Who eats meals with you?
- B. How do you prepare your food?
- C. Do you eat three meals per day?
- D. Do you snack in the evening?
Correct Answer: B
Rationale: Asking the client how food is prepared gives the nurse and dietitian the ability to judge the sodium content. Typically, canned or prepared food and food from a restaurant will have elevated sodium levels. Sodium content in food prepared from fresh ingredients is usually minimal. Asking about whom the client eats with or the client's eating patterns are not as helpful in determining sodium content.
The nurse is working on a busy cardiac unit caring for four hypertensive clients. Which client description would the nurse assess first because the client is at an increased risk for malignant hypertension?
- A. A client with anorexia and history of no health care insurance
- B. A client with liver dysfunction who drinks alcohol daily
- C. A schizophrenic residing at an assisted living facility
- D. A client with chronic asthma who uses a corticosteroid inhaler
Correct Answer: A
Rationale: Accelerated and malignant hypertension can occur in individuals who fail to maintain follow-up or comply with medical therapy. Those individuals who have no health care insurance often are unable to obtain the medical follow-up or afford the cost of medications to treat the hypertensive state. If the hypertension is untreated, symptoms and complication can rapidly follow. The other choices need further assessment but are not the priority.
The nurse is teaching a client about hypertension and the effects on the left ventricle. What diagnostic test will the nurse describe?
- A. echocardiography
- B. computed tomographic (CT) scan
- C. fluorescein angiography
- D. positron emission tomography (PET) scan
Correct Answer: A
Rationale: Echocardiography will reveal an enlarged left ventricle. Fluorescein angiography reveals leaking retinal blood vessels, and a PET scan is used to reveal abnormalities in blood pressure. A CT scan reveals structural abnormalities.