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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.
Choice B rationale:
A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.
Choice C rationale:
A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.
Choice D rationale:
Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.
Correct Answer is D
Explanation
Choice A rationale:
Taking a daily walk is a beneficial activity for patients with venous leg ulcers. Walking promotes blood circulation, which can aid in wound healing. This statement indicates that the patient understands the importance of physical activity for their condition.
Choice B rationale:
Trying to lose weight is another positive step for a patient with venous leg ulcers, especially if the patient is overweight. Excess body weight can put additional pressure on the veins in the legs, worsening venous insufficiency. Losing weight can alleviate this pressure and improve venous circulation, supporting the healing process of leg ulcers.
Choice C rationale:
Wearing stockings after getting out of bed is a proper technique for managing venous leg ulcers. Compression stockings help improve blood flow in the legs and reduce swelling, which is beneficial for patients with venous insufficiency and leg ulcers. This statement indicates that the patient understands the importance of wearing compression stockings consistently.
Choice D rationale:
Not wearing knee-high socks that are tight around the calf is essential advice for patients with venous leg ulcers. Tight clothing, including socks or stockings, can impede blood circulation in the legs, worsening venous insufficiency and delaying wound healing. This statement indicates the need for further education because the patient should avoid any tight clothing around the affected area to promote optimal blood flow and wound healing.
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