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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hypokalemia can cause muscle weakness and cramps, but it does not typically lead to severe muscle spasms causing exhaustion. The patient’s symptoms of lethargy and weakness are more likely related to electrolyte imbalances and dehydration rather than muscle spasms.
Choice B rationale
While low potassium levels can affect cellular metabolism, the primary issue here is not glycolysis. The patient’s symptoms are more consistent with dehydration and electrolyte imbalances rather than a metabolic shift to glycolysis.
Choice C rationale
Hypokalemia can cause cells to become hyperpolarized, leading to muscle weakness and decreased reflexes. However, the patient’s symptoms of lethargy and weakness are more likely due to dehydration and electrolyte imbalances rather than cellular hyperpolarization.
Choice D rationale
Hypernatremia, or high sodium levels, can cause cellular dehydration, leading to symptoms such as lethargy and weakness. The patient’s lab results and clinical presentation are consistent with hypernatremia-induced cellular dehydration, which explains his symptoms.
Correct Answer is B
Explanation
Choice A rationale
Decreasing the secretion of thyroid stimulating hormone (TSH) by the pituitary gland is not a compensatory response to fluid volume deficit. TSH primarily regulates thyroid function and metabolism, and its secretion is not directly related to fluid balance or osmolality.
Choice B rationale
Increasing renin-angiotensin-aldosterone system (RAAS) activity by the kidneys is the body’s primary compensatory response to fluid volume deficit. When there is a decrease in blood volume or blood pressure, the kidneys release renin, which activates the RAAS. This system increases the reabsorption of sodium and water in the kidneys, leading to an increase in blood volume and blood pressure.
Choice C rationale
Decreasing the secretion of cortisol by the adrenal gland is not a compensatory response to fluid volume deficit. Cortisol is a stress hormone that helps regulate metabolism, immune response, and other functions, but it is not directly involved in fluid balance.
Choice D rationale
Increasing the secretion of natriuretic peptides by the heart is a response to fluid overload, not fluid deficit. Natriuretic peptides promote the excretion of sodium and water by the kidneys, which helps reduce blood volume and pressure. This response is opposite to what is needed in a fluid volume deficit situation.
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