A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

"Have you recently taken any antihistamines?"

"Have there been recent stressful events in your life?"

"Did you take any acetaminophen today?"

"Have you consistently taken your medications?"

Answer and Explanation

The Correct Answer is D

Choice D: This question is crucial as it addresses the client's adherence to their prescribed medication regimen for managing high blood pressure. Consistent medication use is essential for controlling blood pressure and reducing the risk of complications associated with hypertension. The elevated blood pressure reading suggests that the current medication regimen may not be effectively controlling the client's blood pressure. By assessing medication adherence, the nurse can determine if non-adherence is contributing to the high blood pressure reading or if adjustments to the medication regimen are required.

"Have you recently taken any antihistamines?": Asking about recent antihistamine use is not directly relevant to the client's high blood pressure reading of 210/106 mm Hg. Antihistamines are medications primarily used to relieve allergy symptoms and do not typically have a signiﬁcant impact on blood pressure levels.

"Have there been recent stressful events in your life?": While stress can contribute to temporary increases in blood pressure, asking about recent stressful events is not the most critical follow-up question in this situation. The client's blood pressure reading of 210/106 mm Hg indicates a severe elevation that requires immediate attention and management beyond stress reduction alone.

"Did you take any acetaminophen today?": Acetaminophen, also known as paracetamol, is a pain reliever and fever reducer. It does not typically have a signiﬁcant effect on blood pressure. Therefore, asking about acetaminophen use is not the most relevant follow-up question for the client's high blood pressure reading.

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Correct Answer is B

Explanation

Defibrillation is not the first-line treatment for atrial fibrillation. It is used to treat life-threatening cardiac arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. Atrial fibrillation, on the other hand, is a rapid and irregular atrial rhythm, and defibrillation is not indicated for its treatment.

Obtain consent for transesophageal echocardiogram (TEE): This is an appropriate action for a client with atrial fibrillation. A TEE is often performed to assess the structure and function of the heart in cases of atrial fibrillation, especially when considering cardioversion or other interventions.

Obtain consent for cardioversion: Cardioversion is a common treatment option for atrial fibrillation, especially when the client is unstable or experiencing symptoms. It involves restoring a normal heart rhythm through the use of electrical shocks or medications. It is important to obtain informed consent before performing cardioversion, but this does not necessarily require questioning.

Hold digoxin 48 hours prior to cardioversion: Digoxin is commonly held before cardioversion because it can increase the risk of certain arrhythmias during the procedure. This is a standard precaution to minimize potential adverse effects. Therefore, the nurse does not need to question this action, as it aligns with established guidelines.

A. Assess pulse of affected extremity every 15 minutes at ﬁrst. B. Palpate the affected leg for pain during every assessment C. Assess the client for signs and symptoms of compartment syndrome every 2 hours. D. Perform Doppler evaluation once daily.

Correct Answer is ["A","B","C","D"]

Explanation

Assess pulse of the affected extremity every 15 minutes at ﬁrst: Frequent assessment of the pulse in the affected extremity is important to monitor for any changes in blood ﬂow. This allows the nurse to identify any potential complications such as graft occlusion or compromised circulation promptly.

Palpate the affected leg for pain during every assessment: Assessing for pain in the affected leg is crucial to identify any signs of ischemia or inadequate perfusion. Increased pain could indicate reduced blood ﬂow or other complications that require immediate attention.

Assess the client for signs and symptoms of compartment syndrome every 2 hours: Compartment syndrome can occur after vascular surgeries, and early recognition is vital. The nurse should assess for signs and symptoms such as pain, numbness, tingling, increased swelling, and tense compartments. Regular assessment every 2 hours can help detect compartment syndrome promptly and prevent further complications.

Perform Doppler evaluation once daily: Doppler evaluation may be ordered by the healthcare provider to assess blood ﬂow and graft patency. However, the frequency of Doppler evaluation may vary depending on the client's condition and the healthcare provider's orders. Once daily assessment is not suﬃcient if there are concerns regarding blood ﬂow or graft viability.

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A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

Nursing Test Bank

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