A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?

Initiate an IV dopamine infusion.

Begin an IV bolus of lactated Ringer's.

Perform neurological assessments.

Place the client supine.

Answer and Explanation

The Correct Answer is C

A hypertensive crisis is an emergent situation in which a marked elevation in diastolic blood pressure can cause end-organ damage.
The nurse should perform neurological assessments to monitor for any changes in the patient’s level of consciousness and other neurological symptoms.
Choice A is incorrect because dopamine is not typically used to treat hypertensive crises.
Choice B is incorrect because lactated Ringer’s solution is not typically used to treat hypertensive crises.
Choice D is incorrect because placing the client supine may not be appropriate and could potentially worsen their condition.

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Correct Answer is D

Explanation

White rice is a low-potassium food that can be recommended for a client who has chronic kidney disease and must limit potassium intake.
Nonfat yogurt (choice A) contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.
A medium baked potato with skin (choice B) is high in potassium and should be limited to a low-potassium diet.
Peanut butter (choice C) also contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.

A. Glasgow Coma Scale score changes from 14 to 9. B. WBC count changes from 9,000 to 16,000/mm. C. Pulse pressure changes from 30 to 20 mm Hg. D. Bilateral pupil diameter changes from 4 to 2 mm.

Correct Answer is A

Explanation

A decrease in the Glasgow Coma Scale (GCS) score indicates a decline in the client’s level of consciousness and neurological function.
This can be a sign of increased intracranial pressure or other complications related to the skull fracture.
Choice B is incorrect because an increase in WBC count may indicate an infection, but it is not as concerning as a decrease in GCS score.
Choice C is incorrect because a change in pulse pressure may indicate changes in cardiovascular function, but it is not as concerning as a decrease in GCS score.
Choice D is incorrect because a change in pupil diameter may indicate changes in neurological function, but it is not as concerning as a decrease in GCS score.

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A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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