A nurse is doing a community teaching about the consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply.

Cerebrovascular disease

Venous insufficiency

Transient Ischemic Attack (TIA)

Left Ventricular Hypertrophy

Constipation

Bronchitis

Answer and Explanation

Correct Answer : A,C,D

A) Cerebrovascular disease: Uncontrolled hypertension can lead to cerebrovascular disease, including stroke. High blood pressure damages the blood vessels in the brain, increasing the risk of both ischemic and hemorrhagic strokes. Chronic hypertension contributes to the development of atherosclerosis and can lead to significant cerebrovascular complications.
B) Venous insufficiency: Venous insufficiency is typically associated with conditions that affect the veins, such as chronic venous disease or deep vein thrombosis, rather than hypertension. While hypertension can impact overall cardiovascular health, it is not a primary cause of venous insufficiency.
C) Transient Ischemic Attack (TIA): A TIA, often referred to as a "mini-stroke," is a temporary period of symptoms similar to those of a stroke. Uncontrolled hypertension is a major risk factor for TIAs, as it can cause temporary disruptions in blood flow to the brain, leading to symptoms that resolve within minutes to hours but indicate a higher risk for a full-blown stroke.
D) Left Ventricular Hypertrophy: Left ventricular hypertrophy (LVH) occurs when the heart's left ventricle becomes thickened due to increased pressure workload, commonly from uncontrolled hypertension. This condition can lead to heart failure, arrhythmias, and other cardiovascular problems.
E) Constipation: Constipation is generally not a direct consequence of uncontrolled hypertension. While lifestyle factors such as diet can affect both hypertension and bowel movements, constipation itself is not directly linked to high blood pressure.
F) Bronchitis: Bronchitis, an inflammation of the bronchial tubes, is not directly related to hypertension. It is more commonly associated with smoking, infections, and chronic lung

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Correct Answer is D

Explanation

A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.

A. Right knee +1; Left knee 0 B. Right knee +3; Left knee +2 C. Right knee +2; Left knee +1 D. Right knee +4; Left knee +3

Correct Answer is C

Explanation

A) Right knee +1; Left knee 0: The scale for grading reflexes typically ranges from 0 to 4. A score of 0 indicates no reflex, which does not align with the description of having a diminished but not absent reflex. A score of +1 suggests a reduced but present reflex, which would be appropriate for a diminished reflex on the left side.

B) Right knee +3; Left knee +2: A score of +3 indicates an exaggerated or brisk reflex, while +2 denotes a normal reflex. Since the right knee reflex is normal, it should be documented as +2. A diminished reflex on the left side is more accurately reflected by a score of +1, not +2.
C) Right knee +2; Left knee +1: This is the most accurate documentation. A score of +2 denotes a normal reflex, which applies to the right knee. A score of +1 reflects a diminished reflex, which is appropriate for the left knee where the reflex is present but reduced.
D) Right knee +4; Left knee +3: A score of +4 represents a very brisk or hyperactive reflex, which is not consistent with a normal finding. Similarly, a score of +3 would indicate an exaggerated reflex, which does not fit the description of the right knee being normal. The correct grading for a normal reflex is +2, and for a diminished reflex is +1.

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A nurse is doing a community teaching about the consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Correct Answer is D

Explanation

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Correct Answer is C

Explanation

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