A female patient with chronic hypertension is admitted to the emergency department with a sudden rise in blood pressure (BP) Which question is the priority for the nurse to ask the patient?
"Are you pregnant?”
"Do you need to urinate?”
"Do you have a headache or confusion?”
"Are you taking antiseizure medications?”
The Correct Answer is C
Choice A rationale:
While pregnancy can contribute to increased blood pressure, it is not the priority question in this scenario. The sudden rise in blood pressure could indicate a hypertensive crisis, which needs immediate attention.
Choice B rationale:
Urination is not directly related to sudden rises in blood pressure. While urinary issues could be a sign of certain conditions, they are not the priority when dealing with a hypertensive emergency.
Choice C rationale:
A sudden rise in blood pressure can lead to symptoms such as headache and confusion, which could indicate a hypertensive crisis. This question is crucial to assess neurological symptoms, which can be indicative of target organ damage due to hypertension.
Choice D rationale:
Antiseizure medications are not directly related to sudden increases in blood pressure. Neurological symptoms (like those in choice C) are more indicative of a hypertensive crisis and require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Silent ischemia refers to a lack of oxygen to the heart that doesn't cause symptoms like chest pain. It is often diagnosed during an electrocardiogram (ECG) done for other reasons. The patient in this scenario is experiencing chest pain, so silent ischemia is not the correct choice.
Choice B rationale:
Angina decubitus refers to chest pain that occurs while lying down and is relieved by standing or sitting. The patient in this scenario is experiencing chest pain at rest, which is not characteristic of angina decubitus.
Choice D rationale:
Chronic stable angina is chest pain or discomfort that typically occurs with activity or stress and is relieved by rest or nitroglycerin. The patient in this scenario is experiencing chest pain at rest, which is not characteristic of chronic stable angina.
Correct Answer is D
Explanation
The correct answer is choice d. pH = 7.52, PaCO2 = 24 mm Hg, PaO2 = 85 mm Hg, and HCO3 = 24 mEq/L.
Rationales:
Choice A rationale:
- pH = 7.46: This value is slightly alkalotic.
- PaCO2 = 44 mm Hg: This is within the normal range (35-45 mm Hg), indicating that the respiratory system is not contributing to alkalosis.
- PaO2 = 95 mm Hg: This is a normal oxygen level.
- HCO3 = 36 mEq/L: This is elevated, indicating metabolic alkalosis rather than respiratory alkalosis.
Choice B rationale:
- pH = 7.27: This value is acidic, indicating acidosis.
- PaCO2 = 70 mm Hg: This is elevated, indicating respiratory acidosis.
- PaO2 = 80 mm Hg: This is slightly low, indicating mild hypoxemia.
- HCO3 = 26 mEq/L: This is within the normal range, indicating no metabolic compensation.
Choice C rationale:
- pH = 7.30: This value is acidic, indicating acidosis.
- PaCO2 = 35 mm Hg: This is within the normal range, indicating that the respiratory system is not contributing to acidosis.
- PaO2 = 70 mm Hg: This is low, indicating hypoxemia.
- HCO3 = 20 mEq/L: This is low, indicating metabolic acidosis.
Choice D rationale:
- pH = 7.52: This value is alkalotic.
- PaCO2 = 24 mm Hg: This is low, indicating respiratory alkalosis.
- PaO2 = 85 mm Hg: This is a normal oxygen level.
- HCO3 = 24 mEq/L: This is within the normal range, indicating no metabolic compensation.
Choice D corresponds with respiratory alkalosis because the pH is alkalotic, and the PaCO2 is low, indicating that the respiratory system is causing the alkalosis. The HCO3 is within the normal range, showing no metabolic compensation.
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