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 B

Explanation

The most important finding to report to the healthcare provider in a client admitted to the intensive care unit (ICU) with a hypertensive emergency is option B, "The client cannot move the left arm and leg when asked to do so."

Hypertensive emergencies are critical situations where extremely high blood pressure levels can lead to damage or dysfunction in vital organs, such as the brain, heart, kidneys, and eyes. Neurological symptoms are particularly concerning in this context, as they may indicate acute brain injury or stroke resulting from uncontrolled high blood pressure.

Option A, "Tremors are noted in the fingers when the client extends the arms," could be concerning but is not as immediately critical as the neurological deficit described in option B. Tremors can have various causes and may not directly relate to the hypertensive emergency unless other signs or symptoms of neurologic impairment are also present.

Option C, "Urine output over 8 hours is 250 mL less than the fluid intake," is relevant to monitor the client's fluid status and kidney function, but it does not indicate an acute, life-threatening condition that requires immediate attention like the neurological deficit in option B.

Option D, "The client reports a headache with pain at level 7 of 10 (0 to 10 scale)," is concerning and may be a symptom of the hypertensive emergency, but it is not as urgent as the neurological findings. Headache can be a symptom of elevated blood pressure, but it is not sufficient on its own to determine the severity of the hypertensive crisis.

In a hypertensive emergency, the priority is to identify and manage potential complications, such as neurological deficits, acute organ damage, or signs of target organ dysfunction. Prompt reporting of any neurological changes is crucial, as it may prompt immediate interventions to prevent further neurological deterioration. The healthcare provider needs to assess the client's neurological status promptly and determine appropriate management to prevent further complications.

A. Decreased hematocrit and diuresis B. Decreased serum creatinine and weight loss C. Increased potassium level and improved appetite D. Decreased white blood cell count and diaphoresis

Correct Answer is B

Explanation

Hemodialysis is a treatment used to remove waste products and excess fluids from the blood in individuals with kidney failure or chronic kidney disease. The primary purpose of hemodialysis is to filter and clear the blood of waste products that the kidneys can no longer remove adequately. As a result, one of the key indicators that hemodialysis is having the desired effect is a decrease in serum creatinine levels. Creatinine is a waste product that builds up in the blood when the kidneys are not functioning properly. A decrease in serum creatinine indicates that the dialysis treatment is effectively removing waste products from the blood.

Weight loss is also a positive sign after hemodialysis since it indicates that excess fluid is being removed from the body. In individuals with kidney failure, the kidneys cannot adequately remove extra fluid, leading to fluid retention and weight gain. Hemodialysis helps to eliminate this excess fluid, leading to weight loss and reducing the risk of fluid overload-related complications.

The other options listed (decreased hematocrit and diuresis, increased potassium level and improved appetite, and decreased white blood cell count and diaphoresis) are not direct indicators of the effectiveness of hemodialysis in removing waste products and excess fluid from the blood.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

Correct Answer is B

Explanation

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

Correct Answer is B

Explanation

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

client with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse?

After the nurse gives IV atropine to a patient with symptomatic type 1. second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?

The nurse identifies that a patient with chronic kidney disease is at risk for which electrolyte disturbance?