ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 27 : Caring for Clients With Hypertension Questions
Question 1 of 5
The nurse is instructing a client who is newly prescribed an antihypertensive medication. Which nursing instruction is emphasized to maintain client safety?
Correct Answer: B
Rationale: The nursing instruction emphasized to maintain client safety is to sit on the edge of the chair before rising slowly. By doing so, the client reduces the possibility of falls related to postural hypotension. Using a pillbox to store medications and taking the medication at the same time daily is good medication management instruction, but not necessarily related to safety. There is no reason when taking antihypertensive medications to restrict driving.
Question 2 of 5
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?
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 (MUG
A). 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.
Question 3 of 5
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?
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.
Question 4 of 5
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?
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.
Question 5 of 5
The nurse is caring for a client who is ordered diazoxide IV to decrease blood pressure. Which nursing consideration is a priority?
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.