Nokea
The nurse obtains a blood pressure of $136 / 86 \mathrm{~mm} \mathrm{Hg}$ on a morning assessment of a client with history of hypertension. Which pressure is of most concern when considering ventricular relaxation?
- A. Central aortic pressure
- B. Systolic pressure
- C. Diastolic pressure
- D. Central venous pressure
Correct Answer: C
Rationale: Diastolic blood pressure reflects arterial pressure during ventricular relaxation. It depends on the resistance of the arterioles and the diastolic filing times. Central aortic pressure is the blood pressure pumped from the left ventricle and measured at the root of the aorta. Systolic blood pressure is determined by the force and volume of blood that the left ventricle ejects. Central venous pressure reflects the blood pressure returning to the heart.
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The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client?
- A. peripheral edema
- B. right-sided heart failure
- C. stroke
- D. pulmonary insufficiency
Correct Answer: C
Rationale: A stroke occurs if vessels in the brain rupture and bleed. If an aneurysm has developed in the aorta from chronic hypertension, it may burst and cause hemorrhage and shock. Peripheral edema, right-sided heart failure, and pulmonary insufficiency are not usually consequences of untreated chronic hypertension.
The nurse is caring for a client with accelerated hypertension. Which body system would the nurse assess to identify early signs of blood pressure progression?
- A. Eyes
- B. Kidney
- C. Heart
- D. Musculoskeletal system
Correct Answer: A
Rationale: Accelerated hypertension is defined as a markedly elevated blood pressure with symptoms of hemorrhages and exudates in the eyes. If the hypertension is untreated, accelerated hypertension progresses to malignant hypertension with symptoms of papilledema. Long-standing hypertension can produce changes in the kidney, heart, and musculoskeletal system.
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.
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 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.