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The physician is ordering a test for the hypertensive client that will be able to evaluate whether the client has experienced heart damage. Which diagnostic test would the nurse anticipate to determine heart damage?
- A. Blood chemistry
- B. Multiple gated acquisition scan (MUGA)
- C. Chest radiograph
- D. Fluorescein angiography
Correct Answer: B
Rationale: The nurse realizes that undiagnosed (untreated), long-standing hypertension can cause heart damage. The diagnostic test that best determines heart damage is the multiple gate acquisition scan (MUGA). This test is used to detect how efficiently the heart pumps. A blood chemistry determines electrolyte balance. A chest radiograph (chest $x$-ray) can provide details of the heart size through shading on the scan. Fluorescein angiography is an ophthalmologic test revealing leaking retinal blood vessels.
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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 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.
Which of the following is the nurse most correct to recognize as a direct effect of client hypertension?
- A. Renal dysfunction resulting from atherosclerosis
- B. Anemia resulting from bone marrow suppression
- C. Hyperglycemia resulting from insulin receptor resistance
- D. Emphysema related to poor gas exchange
Correct Answer: A
Rationale: The nurse is most correct to realize high blood pressure damages the arterial vascular system and accelerates atherosclerosis. The effect of the atherosclerosis impairs circulation to the kidney, resulting in renal failure. Neither anemia, hyperglycemia, nor emphysema occurs as a direct effect of hypertension.
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 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.