A nurse is assessing a client with intermittent claudication. What client statement supports this information?

"My feet feel like I have pins and needles."

"When I stand or sit too long, my feet swell."

"My legs get a painful cramp when I walk over 30 minutes."

"I get short of breath when I climb a lot of stairs.”

Answer and Explanation

The Correct Answer is C

The client statement that supports the information of intermittent claudication is: "My legs get a painful cramp when I walk over 30 minutes.": Intermittent claudication is a symptom of peripheral artery disease (PAD) characterized by pain, cramping, or fatigue in the muscles of the lower extremities, typically the calves, thighs, or buttocks. This pain is usually triggered by physical activity, such as walking, and is relieved with rest. The pain is caused by inadequate blood flow and oxygen supply to the muscles due to narrowed or blocked arteries.

The other client statements do not specifically indicate intermittent claudication:

"My feet feel like I have pins and needles": This sensation of pins and needles is often associated with peripheral neuropathy, which is a condition involving nerve damage and does not directly relate to intermittent claudication.

"When I stand or sit too long, my feet swell": This statement suggests the possibility of venous insufficiency rather than intermittent claudication. Venous insufficiency involves impaired blood return from the legs to the heart and may result in swelling, aching, or heaviness in the legs.

"I get short of breath when I climb a lot of stairs": This symptom is more indicative of cardiovascular or respiratory issues, such as heart or lung disease, rather than intermittent claudication. It suggests that the client may experience exercise intolerance due to cardiopulmonary limitations.

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Correct Answer is C

Explanation

Maintaining a 2 gram-sodium (salt) diet is an important aspect of managing hypertension. High sodium intake can contribute to elevated blood pressure. Therefore, reducing sodium intake is recommended to help control blood pressure levels. The nurse should provide guidance on reading food labels, avoiding high-sodium processed foods, and incorporating a diet rich in fruits, vegetables, and whole grains.

The other options listed are not appropriate or beneficial for managing hypertension:

Maintaining a low-potassium diet: Potassium is an essential mineral that helps regulate blood pressure. While specific potassium restrictions may be necessary for some individuals with certain medical conditions, most people with hypertension do not need to limit their potassium intake. In fact, a balanced diet with adequate potassium is generally recommended.

Skipping a medication dose if dizziness occurs: It is not advisable to skip medication doses without consulting a healthcare provider. Hypertension medications are prescribed to help control blood pressure, and missing doses can lead to uncontrolled hypertension and potential complications. If the client experiences dizziness or other side effects from the medication, they should consult their healthcare provider for appropriate management.

Drinking three glasses of wine a day: Excessive alcohol consumption can contribute to elevated blood pressure. The recommended alcohol intake for individuals with hypertension is moderate or limited to moderate levels, which typically means no more than one drink per day for women and two drinks per day for men. Drinking excessive amounts of wine or any alcoholic beverage can negatively affect blood pressure control.

A. Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night. B. Use an automated noninvasive blood pressure machine to obtain frequent measurements. C. Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting. D. Assist the patient up in the chair for meals to avoid complications associated with immobility.

Correct Answer is B

Explanation

The action that will be included in the plan of care for a client in a hypertensive emergency receiving nifedipine is to use an automated noninvasive blood pressure machine to obtain frequent measurements.

In a hypertensive emergency, the client's blood pressure is severely elevated, requiring immediate treatment and close monitoring. Nifedipine is a calcium channel blocker commonly used to lower blood pressure in such situations. Continuous blood pressure monitoring is crucial to assess the effectiveness of the medication and ensure that the blood pressure is brought under control safely.

Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night: While providing a conducive environment for sleep is important for overall patient well-being, in a hypertensive emergency, the priority is to manage and monitor the blood pressure. Sleep hygiene may not be the immediate concern in this situation.

Keep the hypertensive emergency NPO to prevent aspiration caused by nausea and possible vomiting: NPO (nothing by mouth) orders are typically implemented when there is a risk of aspiration or pending a procedure requiring anesthesia. In a hypertensive emergency, the focus is on managing blood pressure and ensuring appropriate hydration and nutrition as needed. NPO status may not be necessary unless speciﬁcally indicated for the individual patient.

Assist the patient up in the chair for meals to avoid complications associated with immobility: While mobilization and preventing complications associated with immobility are important aspects of care, in a hypertensive emergency, the primary focus is on managing blood pressure and stabilizing the client's condition. Mobilization may be appropriate once the blood pressure is under control and the client's condition permits.

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A nurse is assessing a client with intermittent claudication. What client statement supports this information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge education to a client with hypertension. Which essential information should the nurse include in the teaching plan?

Correct Answer is C

Explanation

The nurse is caring for a client in a hypertensive emergency. Which action will be included in the plan of care during hypertensive emergency who is receiving nifedipine?

Correct Answer is B

Explanation

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