A client with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department. The client reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?

"Have you recently taken any antihistamines?"

"Have there been recent stressful events in your life?"

"Have you consistently taken your medications?"

"Did you take any acetaminophen/Tylenol) today?"

Answer and Explanation

The Correct Answer is B

The client presenting to the emergency department with a severe headache, nausea, and significantly elevated blood pressure (BP) of 238/118 mm Hg indicates a hypertensive crisis, which is a severe and potentially life-threatening condition. In such cases, the nurse's priority is to assess for potential triggers or exacerbating factors for the hypertensive crisis.

Option B, "Have there been recent stressful events in your life?" is the most relevant question to follow up on the findings. Stress is a known trigger for acute elevations in blood pressure, and severe stress can lead to a hypertensive crisis in individuals with a history of hypertension. Identifying recent stressful events may help the nurse understand potential contributing factors to the client's current condition and guide the management plan.

Option A, "Have you recently taken any antihistamines?" is not the most relevant question in this situation. Antihistamines are not typically associated with causing a hypertensive crisis. While certain medications and substances can interact with antihypertensive medications, causing an increase in BP, the severity of the client's symptoms and the extremely high BP reading suggest that a more immediate concern needs to be addressed.

Option C, "Have you consistently taken your medications?" is important for assessing medication adherence, but it may not directly explain the acute hypertensive crisis. The client's current symptoms and BP reading require more immediate investigation into potential triggers.

Option D, "Did you take any aspirin (or Tylenol) today?" is relevant to assess whether the client has recently taken any over-the-counter medications that could potentially interact with their prescribed antihypertensive drugs. However, it is not the most critical question to address the hypertensive crisis and the severity of the client's symptoms.

Given the severity of the client's presentation, the nurse should also promptly initiate appropriate interventions to address the hypertensive crisis, such as administering antihypertensive medications as prescribed, monitoring vital signs frequently, and notifying the healthcare provider for further evaluation and management.

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Correct Answer is C

Explanation

This statement indicates effective learning because serum cardiac markers are indeed proteins that are released from necrotic (damaged) heart muscle cells when there is myocardial injury, such as in acute coronary syndrome (ACS). These markers are measured in blood tests and help in the diagnosis and assessment of ACS, particularly myocardial infarction (heart attack).

Option A is incorrect because a nitroprusside stress echocardiogram is not used for acute pericarditis. It is a diagnostic test used for evaluating coronary artery disease and ischemia.

Option B is incorrect because a pathologic Q wave is not always present in the electrocardiogram (ECG) of patients with unstable angina. It is a characteristic finding in the ECG of patients with a previous myocardial infarction (heart attack) but may not be present in unstable angina.

Option D is incorrect because coronary angiography is not the only way to confirm the diagnosis of unstable angina. Unstable angina is primarily diagnosed based on the clinical presentation, symptoms, and changes in the ECG. Coronary angiography is an invasive procedure used to visualize the coronary arteries directly and is typically reserved for cases where further assessment and intervention are needed, such as in cases of suspected coronary artery disease.

A. IV morphine sulfate 4 mg B. Oral acetaminophen (Tylenol) 650 mg C. Oral ibuprofen (Motrin) 600 mg D. Fentanyl 1 mg IV

Correct Answer is C

Explanation

Pericarditis is inflammation of the pericardium, the sac-like membrane surrounding the heart. It can cause chest pain, which is often worsened by deep breathing or coughing. The goal of treatment for pericarditis is to reduce inflammation and relieve pain.

In this case, the client's pain level is reported as 6 out of 10. As per the PRN (as-needed) medication options given:

C) Oral ibuprofen (Motrin) 600 mg: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and can help reduce inflammation and relieve pain in cases of pericarditis. It is an appropriate choice for this client's pain level of 6 out of 10.

A) IV morphine sulfate 4 mg: IV morphine is a potent opioid analgesic and may be appropriate for severe pain. However, in this case, the client's pain level is moderate (6 out of 10), and it is not the first-line medication for pericarditis pain.

B) Oral acetaminophen (Tylenol) 650 mg: Acetaminophen is a mild analgesic and antipyretic that can be effective for mild to moderate pain. However, in this situation, the client's pain is moderate (6 out of 10), and acetaminophen alone may not provide adequate relief for pericarditis pain.

D) Fentanyl 1 mg IV: Fentanyl is another potent opioid analgesic. However, similar to morphine, it may be more appropriate for severe pain, not moderate pain like in this scenario.

Based on the client's pain level and the goal of reducing inflammation, the most appropriate PRN medication for the nurse to give is oral ibuprofen (Motrin) 600 mg.

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Naxlex Comprehensive Predictor Exams

The nurse teaches a student nurse about diagnostic studies used for acute coronary syndrome. Which statement made by the student nurse indicates effective learning?

Correct Answer is C

Explanation

A client recovering from heart surgery develops pericarditis and reports level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give?

Correct Answer is C

Explanation

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

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Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse?

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Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect?

Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?