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 B
Explanation
Rationale:
A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.
B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.
C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.
D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Limit visitors to 30 min per day: Time restrictions help reduce others’ exposure to radiation from the sealed implant. Limiting duration minimizes cumulative exposure for visitors while still allowing social interaction for the client.
B. Place the client in a semi-private room: Clients with internal radiation implants require a private room to protect others from unnecessary radiation exposure. A semi-private room increases the risk of radiation exposure to other patients and is inappropriate.
C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should avoid contact with clients receiving internal radiation entirely, as even minimal exposure could harm the fetus. The safest recommendation is to avoid visiting during treatment.
D. Wear a lead apron when providing care: A lead apron shields the nurse from radiation exposure, especially when working close to the client. This is part of the time, distance, and shielding principles for radiation safety.
E. Close the door to the client's room: Keeping the door closed helps contain radiation within the client’s room, reducing exposure to staff and visitors in nearby areas. This is a standard precaution in caring for clients with sealed implants.
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