A nurse is assessing a client who is experiencing a hypertensive crisis. Which of the following manifestations should the nurse expect?
Skin cool to touch
Jugular vein distention
Headache
Weak peripheral pulses
The Correct Answer is C
Rationale:
A. Skin cool to touch: Cool skin is more commonly associated with shock states or severe peripheral vasoconstriction, not with a hypertensive crisis. In hypertensive crisis, the client is more likely to have warm skin due to increased circulation from elevated blood pressure.
B. Jugular vein distention: While jugular vein distention can occur in right-sided heart failure or severe fluid overload, it is not a hallmark manifestation of hypertensive crisis. The acute issue in hypertensive crisis is extreme elevation in blood pressure with end-organ effects.
C. Headache: Severe headache is a common and classic symptom of hypertensive crisis due to sudden, extreme elevations in blood pressure causing increased ICP and cerebral vessel stress. It often signals an urgent need for BP control to prevent complications such as stroke.
D. Weak peripheral pulses: Weak pulses are more often associated with low cardiac output or severe arterial obstruction. In hypertensive crisis, peripheral pulses are typically bounding and strong because of the elevated systemic vascular resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}
Explanation
Rationale:
- Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
- Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
- Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
- Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
- Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.
Correct Answer is B
Explanation
Rationale:
A. How to change the tracheostomy dressing using clean technique: Tracheostomy dressings should be changed using sterile technique, not clean technique, to prevent infection and protect the airway. Teaching clean technique would be inappropriate.
B. How to operate the portable suction machine: Suctioning is a critical skill for maintaining airway patency and preventing respiratory complications. Teaching the partner how to operate the suction machine ensures they can assist safely at home if needed.
C. How to change the nondisposable tracheostomy tube daily: Nondisposable tracheostomy tubes are not typically changed daily; frequent changes can damage the stoma or airway. Tube changes are usually performed by trained healthcare personnel.
D. How to secure the tracheostomy tube with ties at the back of the neck: Ties should be secured in a way that avoids pressure or friction on the back of the neck, typically fastening at the sides. Focusing on back-of-neck placement could lead to skin breakdown or discomfort.
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