ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 27 : Caring for Clients With Hypertension Questions
Question 1 of 5
Which of the following nursing diagnoses is the nurse most correct to choose when caring for a client with long-standing hypertension?
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.
Question 2 of 5
The nurse is caring for a client with hypertension. The nurse is correct to realize that a 24-hour urine is ordered to determine if the cause of hypertension is related to the dysfunction of what?
Correct Answer: B
Rationale: The 24-hour urine collection specimen is ordered to determine dysfunction of the adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are not evaluated by a 24-hour urine.
Question 3 of 5
The nurse is teaching a client about hypertension and the effects on the left ventricle. What diagnostic test will the nurse describe?
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.
Question 4 of 5
The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client?
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.
Question 5 of 5
The nurse is screening a client at a health fair for hypertension. Which assessment data, provided by the client, would prompt the nurse to stress physician involvement? Select all that apply.
Correct Answer: A,C,D,F
Rationale: When assessing the client for symptoms of hypertension, the nurse should recognize that the client may note fatigue, headache, insomnia, and blurred vision. Other symptoms include dizziness, nervousness, nosebleeds, angina, and dyspnea. Constipation and dysuria are not signs of hypertension.