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
Explanation
Rationale:
A. The child believes the person will return: Preschoolers view death as temporary and reversible due to their developmental stage and limited understanding of permanence. Magical thinking often leads them to expect the deceased person to come back.
B. The child focuses on his own mortality: This is more typical of older school-age children or adolescents, who have a more developed understanding of death’s permanence and may begin to consider their own vulnerability.
C. The child refuses to talk about the death: Avoidance can occur at any age, but it is not the primary expected response in preschoolers. At this stage, they may ask repetitive questions or make statements that suggest misunderstanding, rather than complete refusal to talk.
D. The child expresses curiosity about the death process: Curiosity about death’s physical aspects is more common in school-age children, who have greater cognitive ability to think concretely about biological processes.
Correct Answer is A
Explanation
Rationale:
A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.
B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.
C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.
D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.
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