A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

Blood pressure of 180/120 mmHg.

Heart rate of 90 beats per minute.

Respiratory rate of 20 breaths per minute.

Temperature of 37°C (98.6°F).

Answer and Explanation

The Correct Answer is A

Choice A rationale
A blood pressure reading of 180/120 mmHg or higher is indicative of a hypertensive crisis. This condition requires immediate medical attention to prevent damage to vital organs such as the heart, kidneys, and brain.
Choice B rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate a hypertensive crisis. While it is important to monitor heart rate, it is not a definitive sign of a hypertensive emergency.
Choice C rationale
A respiratory rate of 20 breaths per minute is within the normal range and does not indicate a hypertensive crisis. Respiratory rate alone is not a reliable indicator of hypertensive emergencies.
Choice D rationale
A temperature of 37°C (98.6°F) is normal and does not indicate a hypertensive crisis. Body temperature is not a primary indicator of hypertensive emergencies.

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Correct Answer is D

Explanation

Choice A rationale
Acute respiratory distress syndrome (ARDS) is characterized by severe hypoxemia and respiratory distress, often requiring mechanical ventilation. It is not typically associated with a mild fever and increased respiratory rate.
Choice B rationale
Chronic obstructive pulmonary disease (COPD) is a chronic condition characterized by airflow limitation and respiratory symptoms, but not typically associated with a mild fever.
Choice C rationale
Pulmonary edema involves fluid accumulation in the lungs, leading to respiratory distress and hypoxemia, but not typically associated with a mild fever.
Choice D rationale
Pneumonia is an infection of the lungs causing fever (37.5°C), increased respiratory rate (28 breaths per minute), and other respiratory symptoms. It is the most likely condition given the symptoms.

A. Decreased breath sounds in the lower lobes. B. Increased respiratory rate and use of accessory muscles. C. Elevated blood pressure and heart rate. D. Presence of wheezing and cyanosis.

Correct Answer is B

Explanation

Choice A rationale
Decreased breath sounds in the lower lobes can indicate areas of the lung that are not ventilating well, but this finding alone does not specifically indicate an exacerbation of COPD. It could be due to other conditions such as pleural effusion or atelectasis.
Choice B rationale
Increased respiratory rate and use of accessory muscles are signs of respiratory distress and indicate that the patient is working harder to breathe. These findings are consistent with an exacerbation of COPD, where the airways are more obstructed, and the patient has difficulty maintaining adequate ventilation.
Choice C rationale
Elevated blood pressure and heart rate can occur in many conditions and are not specific indicators of a COPD exacerbation. These vital sign changes can be due to pain, anxiety, or other stressors.
Choice D rationale
Presence of wheezing and cyanosis are also indicators of a COPD exacerbation. Wheezing indicates airway obstruction, and cyanosis indicates hypoxemia, both of which are common during an exacerbation.

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A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a temperature of 37.5°C (99.5°F) and a respiratory rate of 28 breaths per minute. Which condition is the client most likely experiencing?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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