A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion.
The nurse should prioritize which of the following actions?
Administering antihypertensive medication as prescribed.
Preparing the client for a lumbar puncture.
Initiating seizure precautions.
Monitoring the client’s blood glucose levels.
The Correct Answer is A
Choice A rationale
Administering antihypertensive medication as prescribed is the priority action for a client with a history of hypertension presenting with severe headache, blurred vision, and confusion.
These symptoms suggest a hypertensive crisis, which requires immediate blood pressure reduction to prevent further complications.
Choice B rationale
Preparing the client for a lumbar puncture is not the priority action in this scenario. While a lumbar puncture may be necessary to rule out other conditions, the immediate concern is to manage the hypertensive crisis.
Choice C rationale
Initiating seizure precautions is important if the client is at risk of seizures, but the priority action is to address the hypertensive crisis by administering antihypertensive medication.
Choice D rationale
Monitoring the client’s blood glucose levels is important for overall health management, but it is not the priority action in this scenario. The immediate concern is to manage the hypertensive crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Acute respiratory distress syndrome (ARDS) is characterized by severe hypoxemia and respiratory distress, often requiring mechanical ventilation. It is not typically associated with a mild fever and increased respiratory rate.
Choice B rationale
Chronic obstructive pulmonary disease (COPD) is a chronic condition characterized by airflow limitation and respiratory symptoms, but not typically associated with a mild fever.
Choice C rationale
Pulmonary edema involves fluid accumulation in the lungs, leading to respiratory distress and hypoxemia, but not typically associated with a mild fever.
Choice D rationale
Pneumonia is an infection of the lungs causing fever (37.5°C), increased respiratory rate (28 breaths per minute), and other respiratory symptoms. It is the most likely condition given the symptoms.
Correct Answer is B
Explanation
Choice A rationale
Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.
Choice B rationale
Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.
Choice C rationale
Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.
Choice D rationale
Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.
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