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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypercalcemia is characterized by increased calcium levels in the blood, often due to increased absorption of calcium from the gut. However, in chronic kidney disease (CKD), the kidneys’ ability to activate vitamin D is impaired, leading to decreased calcium absorption from the gut, not increased. Therefore, hypercalcemia is not a typical sign of CKD1.
Choice B rationale
A positive Chvostek’s sign is indicative of hypocalcemia, which is a common symptom in CKD. The kidneys’ reduced ability to activate vitamin D leads to decreased calcium absorption from the gut, resulting in low calcium levels in the blood. This hypocalcemia can cause neuromuscular irritability, leading to a positive Chvostek’s sign.
Choice C rationale
Tetany is a condition characterized by muscle cramps and spasms, often due to hypocalcemia. In CKD, hypocalcemia occurs due to the kidneys’ inability to activate vitamin D, leading to decreased calcium absorption from the gut. This hypocalcemia can cause hyperexcitability of nerves and muscles, resulting in tetany.
Choice D rationale
Hyperphosphatemia is characterized by high phosphate levels in the blood. In CKD, the kidneys’ ability to excrete phosphate is impaired, leading to its accumulation in the blood. However, this is not directly related to the inability to absorb phosphate from the gut but rather the kidneys’ reduced excretion capacity.
Correct Answer is A
Explanation
Choice A rationale
Septic shock is a severe infection leading to systemic inflammation, characterized by high fever (39°C), low blood pressure (90/60 mmHg), and signs of organ dysfunction. It is a medical emergency requiring immediate intervention.
Choice B rationale
Cardiogenic shock is caused by the heart’s inability to pump blood effectively, leading to hypotension and signs of poor perfusion, but not necessarily high fever.
Choice C rationale
Neurogenic shock results from a disruption in the autonomic pathways, leading to hypotension and bradycardia, but not high fever.
Choice D rationale
Anaphylactic shock is a severe allergic reaction causing hypotension, respiratory distress, and other symptoms, but not typically high fever.
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